Download Case Study - Taryn P. Berry

Taryn Berry
Drug-Nutrient Interaction Case Study
1. What is depression?
 A depressive disorder or depression is an illness that involves the
body, mind, and thoughts. Depression can lead to negative
connotations about ones self, thoughts about others, sleeping and
eating patterns, and general day-to-day emotions.
 Nutrition Therapy & Pathophysiology 2e, 632.
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 common side effect of SSRIs is weight gain, which might be
attributed to increased appetite, changes in metabolic rate, or
hormonal changes. Some times this lead to non-compliance with the
medication.
 Nutrition Therapy & Pathophysiology 2e, 632.
3. How do selective serotonin reuptake inhibitors (SSRIs) work?
 Selective serotonin reuptake inhibitors help with depression by
interacting with the neurotransmitter serotonin. SSRIs block the
reuptake of serotonin in the brain, which seems to help the brain send
and receive chemical messages, and thus boost mood.
 Mayo Clinic, “Selective serotonin reuptake inhibitors (SSRIs)”
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 prescription in the United States. What is St. John’s wort?
 St. John’s wort is an herbal supplement used to treat depression. It can
also be used to help stop smoking, treatment of fibromyalgia,
migraines, wounds, bug bites, hemorrhoids, nerve pain, heart
palpitations, attention deficit-hyperactivity disorder (ADHD),
obsessive compulsive disorder (OCD) and much more. St. John’s wort
is a plant in which its leaves and flowers are used to make medicine.
 Medline Plus, “St. John’s Wort”
5. How is St. John’s wort used in the United States?
 In the United States, St. John’s wort is used as an herbal supplement
for the treatment of depression. This is not prescribed by physicians
but as a holistic approach to treatment.
 Medline Plus, “St. John’s Wort”
6. How does St. John’s wort work as an antidepressant?
 St. John’s wort works like an SSRI medication and blocks the
synaptosomal uptake of serotonin, dopamine, and noradrenaline. This
results in an antidepressant effect on the body.
 PubMed, “Mechanism of action of St. John’s wort in depression: what
is known?”
7. Does St. John’s wort have any side effects?
 Side effects of St. John’s wort in combination with other
antidepressant prescription medicine can increase production of
serotonin in the brain to life-threatening levels. Psychosis is rare but
has been seen in people with mental health disorders, such as bipolar
disorder. In addition to antidepressants, St. John’s wort can also
weaken prescriptions such as, birth control pills, heart medication,
some HIV drugs, some cancer medications, blood thinners, and
medication that helps the body from rejecting a transplant.
 National Center for Complementary and Integrative Health, “St. John’s
Wort and Depression”
8. How is St. John’s wort regulated in the United States?
 The FDA has not approved St. John’s wort for over the counter or
prescription medicine use in the United States. Currently it is only
used to treat depression by some as a dietary supplement.
 National Center for Complementary and Integrative Health, “St. John’s
Wort and Depression”
9. How is St. John’s wort used in Europe?
 St. John’s wort is widely used in Europe, particularly in Germany, as a
treatment for depression. In Germany, primary care physicians
prescribe St. John’s wort as an herbal supplement for depression,
especially in adolescents and children.
 MNT, “What is St. John’s wort? How effective is St. John’s wort?”
10. Why do you think people are interested in alternative medicine and herbal
treatments?
 I believe that some people are interested in alternative medicine and
herbal supplements because they believe they are safer then taking a
prescription medicine. Some prescriptions are new and have little
research on the long-term side effects. Many alternative and herbal
medicines have been around for thousands of years. I also believe that
herbal supplements are tried when all else fails or people are fed up
with the way prescriptions make them feel or act. Although this may
work for some, it should be highly cautioned because of drug
interactions or adverse reactions that could be life threatening.
11. Because Ms. Geitl is ambulatory, you are able to measure her height and
weight. She is 5’ 11” tall and weighs 160 pounds. 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 to metric numbers.
 5’ 11”=71 in x 2.54 cm/in=180.34 cm
 160 lbs/2.2 kg/lbs=72.7 kg
12. Is Ms. Geitl’s recent weight loss anything to be worried about?
 Ms. Geitl’s recent weight loss did not put her under weight (BMI 22.4)
but if it continues it may be worrisome. Often with depression, some
people have suppressed appetite. If this is the case then her weight
and food diary needs to be closely monitored so she does not keep
losing weight.
 %UBW=160 lbs/165 lbs=97% or a loss of 3%
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
Box 1
Box 2
Box 3
Box 4
Weight loss section (Table 1)
Disease section (Table 2)
Metabolic section (Table 3)
Physical section (Table 4)
Total
Score
1
2
3
3
0
0
0
0
9
SGA Rating: (select one)
A=well nourished
B=moderately (or
suspected of being)
malnourished
C=severely
malnourished
14. Using Appendix I, how would you triage nutritional intervention?
 Because her depression is leading her to being malnourished, I would
say it is important for intervention to take place before her eating
patterns and moods get worse. On the PG-SGA of Nutritional
Assessment her score was 9, which means her SGA Rating is a B. Her
loss of appetite, lethargy, negative mood, and recognition of a problem
with her roommates and teachers indicate that something is out of the
ordinary. Although her nutrition patterns are most likely in response
to her depression, it is important to improve both simultaneously.
15. What methods are available to estimate Ms. Geitl’s energy needs?
 Two methods used to estimate energy needs are Mifflin-St. Jeor and
the Harris Benedict equations.
 Nutrition Therapy & Pathophysiology 2e, 60.
16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed
in Question 15.
 Mifflin-St. Jeor
 10 x 72.7 kg + 6.25 x 180.34 cm – 5 x 20 yrs – 161 =1593 or 1600 kcal
17. What is Ms. Geitl’s estimated energy expenditure?
 1600 kcal x 1.2 activity factor=1900 kcal
o CHO: 55% x 1900 kcal=1045 kcal/4g=261 g
o PRO: 15% x 1900 kcal=285 kcal/4g=71 g
o Fat: 30% x 1900 kcal=570 kca/9g=63 g
18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy
needs?
 Based on both of the evaluations below, she is not getting her needed
energy by about 1250 kcal. Her definition of her typical diet was 670
kcal with 18.4 grams fat, 97 grams carbohydrates, and 33.6 grams
protein. Her 24-hour recall showed 630 kcal with 11.1 grams fat, 83.5
grams carbohydrates, and 51.2 grams protein.
Typical Diet
24-Hour Recall
19. What would you advise?
 Because she is drastically under her needed energy requirements, I
would first discuss her likes and dislikes before her current state. She
currently does not feel hungry so suggesting small frequent meals
would be my first suggestion. Next, I would advise on quick ideas for
lunch because her typical diet recall stated that she normally did not
have time for lunch. I think eating dinner with her roommates is a
good idea so that she feels included, comfortable with eating food, and
it gives her an opportunity to be in the social environment.
20. List each factor from your nutritional assessment and then determine an
expected outcome from each.
Assessment Factor
Inadequate energy
intake
Inadequate
carbohydrate intake
Inadequate protein
intake
Inadequate fat intake
Expected Outcome
Increasing patient’s caloric intake to 1900 kcal. Small
frequent meals, quick lunch ideas, and dinner with
roommate will be suggested to achieve adequate
energy intake.
Increase patient’s carbohydrate intake to 261 g/day.
Suggest fruits, vegetable, and whole grains in order
to achieve this goal.
Increase patient’s protein intake to 71 g/day. Suggest
lean meats, legumes, nuts, and low fat dairy to
achieve this goal.
Increase patient’s fat intake to 63 g/day. Suggest
healthy fats, such as lean meats, nut butters, low fat
dairy, and plant based fats to achieve this goal.
21. What is your immediate concern regarding this patient’s use of St. John’s
wort?


The drug interaction with Zoloft can be life threatening. This is due to
the increased amount of serotonin in the brain reaching a lifethreatening amount, called serotonin syndrome. Additionally, St.
John’s wort interacts with the effectiveness of oral contraceptives.
Because oral contraceptive change hormone levels in women, this
could also impact her emotional state.
Nutrition Therapy & Pathophysiology 2e, 632.
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
 The notation used was the SOAP method, which is an acronym for
Subjective data, Objective data, Assessment, and Plan. This is helpful
to the dietitian and other members of the healthcare team in tracking
the progress and history of the patient. The notes in each section
should be very thorough and detailed so that nothing is looked over.
The note below about Ms. Geitl is lacking in detail.
o S-This section is lacking the fact that she is from Germany.
Family history of her mother having depression and taking
St. John’s wort. Also, the reason for her decreased appetite is
her depression and the other related symptoms should be
listed. The typical diet and 24-hour recall should be under
Objective data. Lastly, her BMI should be included.
o O-This section is pretty detailed but carbohydrate and fat
grams/day should be included. As stated before, typical diet
and 24-hour recall should be in this section.
o A-PES statement should also be included in this section so
the health care team knows the current problems with the
patient.
o P-The goals for reaching carbohydrate, protein, and fat
should be included in this section. The plan for tracking
progress should also be listed in this section.
 Nutrition Therapy & Pathophysiology 2e, 108-109.
References
Butterweck, V. “Mechanism of action of St. John’s wort in depression: what is
known?” PubMed. 2003. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/12775192
“Depression (major depressive disorder).” Mayo Clinic. July 2013. Retrieved from
http://www.mayoclinic.org/diseases-conditions/depression/indepth/ssris/art-20044825?pg=2
Ehrlich, Steven. “St. John’s wort.” University of Maryland Medical Center. May 2011.
Retrieved from http://umm.edu/health/medical/altmed/herb/st-johnswort
Nelms, Sucher, Lacey, Roth. (2012). Nutrition Therapy & Pathophysiology (II ed.):
Belmont, CA: Wadsworth.
Nordqvist, Christian. “What is St. John’s wort? How effective is St. John’s wort?”
MNT. September 2014. Retrieved from http://www.medicalnewstoday.com/
articles/174928.php
“St. John’s wort” MedlinePlus. October 2014. Retrieved from
https://nccih.nih.gov/health/stjohnswort/sjw-and-depression.htm
“St. John’s Wort and Depression.” National Center for Complementary and
Integrative Health. September 2013. Retrieved from
https://nccih.nih.gov/health/stjohnswort/sjw-and-depression.htm