Michelle Hoffman
KNH 413
Drug-Nutrient Interaction Case Study
March 5, 2013
1. What is Depression?
a. Depression is a general yet constant feeling of sadness to the point where
it interferes with the everyday life of the depressed individual as well as
their friends and family. It is generally caused by a combination of
biological, environmental, genetic, and psychological factors and although
anyone is susceptible, the degree severity is not the same for all. There are
theories that suggest depression is linked to a chemical imbalance in the
brain, an idea that is widely known yet has not been fully proven.
However, there is enough research to support the idea that depression is a
disorder of the brain because MRI’s have revealed that the brains of
individuals who have depression are different from those who do not.
i. http://www.nimh.nih.gov/health/publications/depression/what-isdepression.shtml
2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin
reuptake inhibitor (SSRI). Are there any pertinent nutritional
considerations when using this medication?
a. SSRI’s have a number of side effects, and among those are nausea/
vomiting, fatigue, diarrhea, weight loss and changes in appetite. These
effects are of concern because they increase one’s risk for malnutrition,
and they may need to increase their energy intake when on this drug. A
patient taking Zoloft should not consume excessive alcohol either as it
may cause internal damage to the liver and other organs, also putting the
patient as risk for malabsorption of nutrients.
i. http://www.news-medical.net/health/SSRI-Side-Effects.aspx
ii. http://www.drugs.com/food-interactions/sertraline,zoloft.html
3. How do selective serotonin reuptake inhibitors work?
a. SSRIs are medications used to treat mild-to-severe depression that work
by affecting how neurotransmitters communicate between brain cells.
More specifically, they block the reabsorption of serotonin in the brain,
thereby helping brain cells send and receive chemical messages and
boosting the individual’s mood.
i. http://www.mayoclinic.com/health/ssris/MH00066
4. During the diet history, you ask Ms. Geitl if she uses any OTC vitamins,
minerals, or herbal supplements. She tells you her mother suggested she try
Hypericum Perforatum (St. John’s wort) because in Germany it is prescribed
to treat depression. Ms. Geitl did as her mother suggested, as it is available
without a prescription in the United States. What is St. John’s wort?
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a. St. John’s wort is an herb derived from a yellow flowering plant and is
used to treat depression such as anxiety, tiredness, loss of appetite, and
trouble sleeping. The chemical in St. John’s wort known as hyperforin is
thought to be effective against mild to severe depression by acting on
chemical messengers in the nervous system that regulate mood. However
there has been recent concern with the interaction this herb may have if
taken with other prescription drugs (it may limit their effectiveness), and
those considering taking St. John’s wort should first consult their doctor.
i. http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html
ii. http://www.mayoclinic.com/health/st-johns-wort/NS_patientstjohnswort
5. How is St. John’s wort used in the United States?
a. St. John’s wort is used to treat depression in the U.S., although it is not
currently FDA approved in the U.S. for prescription or OTC use because
the evidence that links this herb to treat depression is not conclusive.
Even though this herb cannot be bought in pharmacies in the U.S., it can
still be found in many forms such as tablets, capsules, tea, and liquid
extracts. In some studies conducted in the U.S., St. John’s wort was no
more effective than a placebo in treating various degrees of depression.
i. http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm
6. How does St. John’s wort work as an antidepressant?
a. Studies has shown that St. John’s wort works by preventing nerve cells in
the brain from reabsorbing chemicals, such as dopamine and serotonin,
which are used in regulating mood.
i. http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm
7. Does St. John’s wort have any side effects?
a. This herb is known to have many possible side effects ranging from mild
to severe. Since it increases the levels of serotonin in the brain, taking it
with an antidepressant may cause serotonin syndrome, which can possibly
lead to death if left untreated. Another known side effect of St. John’s
wort is psychosis, and although rare, patients with mental health disorders
are particularly susceptible. It may also weaken the prescription drugs
such as antidepressants, birth control pills, HIV drugs, and even some
cancer medications. Other side effects include anxiety (since this is a
stimulant), upset stomach, diarrhea, fatigue, restlessness, dry mouth,
confusion, and sensitivity to sunlight.
i. http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm
8. How is St. John’s wort regulated in the United States?
a. St. John’s wort is classified as a dietary supplement by the Food and Drug
Administration in the U.S. The FDA has not evaluated St. John’s wort as
a treatment for any medical condition. The FDA claims that it is up to the
consumer to determine whether they believe it is effective and safe to use.
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i. http://www.drugs.com/mtm/st-john-s-wort.html
9. How is St. John’s wort used in Europe?
a. This herb has been used for centuries in Europe (especially Germany) long
before it was introduced in the U.S., where it became known around the
1900s. Since it has been used in Europe to treat depression for so long, is
more widely accepted and in many countries can be bought over the
counter. In addition, the research conducted on the effects of St. John’s
wort in Europe has been generally more positive than in the U.S., and has
even been found to be more affective than a placebo in treating
depression. Finally, besides depression, this herb is used in Europe to
treat burns and skin lesions using topical creams containing St. John’s
wort.
i. http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm
ii. http://www.cancer.org/treatment/treatmentsandsideeffects/comple
mentaryandalternativemedicine/herbsvitaminsandminerals/stjohns-wort
10. Why do you think people are interested in alternative medicine and herbal
treatments?
a. Herbal medicines are “all natural” dietary supplements that are appealing
because of the many health benefits they claim to have. They are also
much cheaper than prescription medication and many types forms are
widely available at drug stores. If taken purely without any prescription
medications, many feel that they are more effective and longer lasting than
prescription medications and come without the possibly detrimental side
effects. In addition, there has been a real shift in the way people think
about their health. Rising health care cost is a factor in the recent surge of
interest in alternative medicine, and many people are attracted to the
alternative physicians emphasis on treating the whole person: body, mind
and spirit.
i. http://www.nlm.nih.gov/medlineplus/herbalmedicine.html
ii. http://www.healthguidance.org/entry/12415/1/Advantages-andDisadvantages-of-Herbal-Medicine.html
11. Because Ms. Geitl is ambulatory, you are able to measure her height and
weight. She is 5’11” tall and weighs 160 lbs. You also determine that she is
of medium frame. Because Ms. Geitl is from Germany, she is used to
reporting her weight in kilograms and her height in centimeters. Convert
her height and weight into metric numbers.
a. Height: 5’ x 12 in.= 60+11=71 in. x 2.54 cm=180.34 cm/100= 1.8034 m
b. Weight: 160 lbs/2.2 kg=72.7 kg
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12. Is Ms. Geitl’s recent weight loss anything to worry about?
a. Due to her depression, her appetite has been very poor, which is the most
likely reason for her recent weight loss. Although a weight loss of 5 lbs.
in three months may not seem severe and isn’t of huge concern at the
moment, it may be the beginning of a more serious problem, and Ms. Geitl
should be carefully monitored for signs of further weight loss. Her dietary
intake should also be watched because her current diet is not as nutrient
dense as it should be.
13. Because Ms. Geitl is alert and cooperative, you ask her to complete a PatientGenerated Subjective Global Assessment (PG-SGA) of Nutritional Status.
How would you score her?
Sections
Score
Box 1- Weight
5 lb. weight loss in past 3 months
Box 2- Food Intake
Less than usual-normal food but less than
normal amount
Box 3- Symptoms
Significantly decreased appetite
Box 4- Activities & Function
Does not feel up to most activities, yet
Weight loss section
1
Disease section
1
Metabolic section
3
Physical section
2
Total 7
SGA Rating: Moderately (or suspected of being) malnourished
http://medsci.indiana.edu/c602web/602/c602web/nutrit/docs/pg_sga.pdf
14. Using Appendix I, how would you triage nutritional intervention?
a. Currently, I would give Ms. Geitl a score of 2-3: patient and family
education by dietitian as indicated by symptom survey and laboratory
values as appropriate. Unless her intervention improves her symptoms of
depression, it is possible for Ms. Geitl’s score to increase.
15. What methods are available to estimate Ms. Geitl’s energy needs?
a. In order to estimate Ms. Geitl’s energy needs, there are several equations
that can be used including the Harris-Benedict Equation, Mifflin-St. Jeor
Equation, American College of Chest Physicians Equation, Penn State
2003 Equation, Ireton-Jones 1997 Equation, Swinamer 1990 Equation,
and WHO Basal Energy Estimation Equation.
16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed
in Question 15.
a. Harris-Benedict Equation for females: 655.1 + 9.6 W(kg) + 1.9 H(cm) –
4.7 A
b. REE= 655.1 + 9.6 (72.7) + 1.9 (180.34) – 4.7 (20) = 1601.67, or 16001700 calories/day
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17. What is Ms. Geitl’s estimated energy expenditure?
a. EER= 354 – 6.91 x age + PA x (9.36 x weight + 726 x height)
b. PA: 1.12 for low active
c. 354 – 6.91 x 20 + 1.12 x (9.36 x 72.7 + 726 x 1.8034)=2444.31, or 20002500 calories/day
18. /19. Evaluate her diet history and 24-hour recall. Is she meeting her energy
needs? What would you advise?
a. Diet-Hx:
b.
24-Hr. Recall:
According to M. Geitl’s usual intake and 24-hr. recall, she is only
consuming around one-third of her estimate energy requirements. In
addition, her diet is not nutrient dense as it lacks most fruits and
vegetables. Her diet is of concern and should be monitored daily in
addition to receiving education tools about ways to increase her appetite as
well as how to consume a well-balanced diet and how that will aid in her
recovery from depression.
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20. List each factor from your nutritional assessment and then determine an
expected outcome from each.
Assessment Factor
Expected Outcome
Caloric Intake
Increased calorie intake through the
consumption of energy-dense foods will
help gain the weight previously lost while
preventing further weight loss
CHO
Increased CHO consumption to meet her
needs, which helps add calories to diet and
improve mood; focus on whole grains
Pro
Increased lean protein intake in order to
meet her needs, add calories and reduce
symptoms in order to add calories and
reduce symptoms
Fat
Increased fat consumption to meet her
needs, focusing on PUFA’s and MUFA’s
and minimizing sat. fat intake
Vitamin D
Increased vitamin D intake and/or sun
exposure to help as it is related to treating
depression
http://www.vitamindcouncil.org/health-conditions/mental-health-and-learningdisorders/depression/
21. What is your immediate concern regarding this patient’s use of St. John’s
wort?
a. My immediate concern is the interaction between St. John’s wort and the
Zoloft Ms. Geitl was prescribed. According to several studies, taking St.
John’s wort with Zoloft tends to increase the side effects of the
antidepressant and could lead to Serotonin Syndrome, where the levels of
serotonin reach a toxic level in the body and could be fatal if left
untreated.
i. http://www.umm.edu/altmed/articles/st-johns-000276.htm
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
a. While the nutrition note may be accurate, it lacks details and is not
complete as it contains omissions needed to create a thorough nutrition
note. The Subjective data section must contain diet-related information,
lifestyle/psychosocial/emotional information, and learning/motivation
information. There isn’t sufficient diet-related information, as it should
have included Ms. Geitl’s alcohol intake as well as psychosocial and
learning/motivation information. For instance, if she appeared tired or
frail upon admission. The Objective data should be information drawn
from physical tests and medical staff observations that are of consequence
to the patient’s nutritional status. Her anthropometric information can be
found here, and in this section her 24-hr. recall and usual intake would be
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more fitting along with her current diagnosis of depression and its onset.
The Assessment category lacks information related to the nutrition
problems with supporting data in the form of PES statements. Finally, the
Olan category describes the outline of interventions necessary to treat each
nutrition problem as specific nutrition therapy recommendations along
with goals and objectives. This SOAP nutrition note does not provide a
timeline for evaluation of the intervention nor provide a plan as to how the
dietitian will adjust Ms. Geitl’s intervention accordingly to her progress.
i. Nutrition Therapy & Pathophysiology, pg. 108
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