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Jillian O’NeilKNH 41302/18/14Case Study 3 – Depression: Drug-Nutrient InteractionWhat is depression?Depression is an “illness that involves the body, mood and thoughts.” This disorder may interfere with the patient’s eating and sleeping habits in addition to a lower self-esteem and thought process (Nelms 632). In addition, depression may affect the patient’s ability to work, study, and ‘enjoy once-pleasurable activities.” It may disable and prevent an individual from a normal day-to-day function routine. Depression may occur as a one-time episode but may also occur as multiple episodes over the course of his or her life (National Institute of Mental Health). 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?First, she may experience extreme thirst. Although it is rare, she may be faced with hypoglycemia due to the medication causing a low blood sugar (National Institute of Mental Health). This antidepressant medication increases serotonin levels and influences mood behaviors. A Vitamin D deficiency may cause depression and therefore, it is important to maintain a well-balanced diet with proper amounts of Vitamin D to prevent an interaction with the medication. (Pfizer) While Zoloft has the ability increase cortisol, it can lower the patient’s glutamine levels. Aside from food interactions, it is not recommended to consume alcohol, other antidepressants, blood thinners, antihistamines, antidiabetic drugs, tranquilizers or additional supplements (ex: St. John’s wort). (U.S. Food and Drug Administration)How do serotonin reuptake inhibitors (SSRIs) work?Serotonin Reuptake Inhibitors, SSRIs, affect neurotransmitters and their communication with brain cells. While blocking the serotonin reabsorption, this type of medication changes the serotonin balance and ultimately improves one’s mood when assisting the cells of the brain send as well as receive chemical message. As most antidepressant medications change the levels of the various neurotransmitters, SSRI affect solely serotonin. (Mayo Clinic)During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals, or herbal supplements. She tells you her mother suggested 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 US. What is St. John’s wort?St. John’s Wort, Hypericum perforatum, is an herb combination of yellow flowers and leaves to create a medicine. The term ‘wort’ was coined meaning plant in Old English. In addition, this combination can be used in oil form by directly applying the oil to skin. This type is used for bruises, scrapes, burns, bug bites, nerve pain, muscle pain, inflammation, and wounds. It is often used for depression and it’s side effects – such as anxiety, decrease in appetite, difficulty sleeping and tiredness. It may also be used for mood disorders, ADHD, OCD, seasonal affective disorder, menopause, heart palpitations, exhaustion, migraines, cancer, nerve pain, muscle pain and irritable bowel syndrome. (Medline Plus)How is St. John’s wort used in the United States?In the United States, St. John’s wart may be used in multiple forms – such as liquid extracts or oils for topical use, tablets, capsules or even in teas. While it is mainly used to treat depression, it is also used for sleeping concerns, anxiety, mood disorders, and other examples as listed in question 4. (Medline Plus). How does St. John’s wort work as an antidepressant?St. John’s wort is comprised of multiple components – specifically consisting of hyperforin. Research has shown that hyperforin extract is the main influence of neurotransmitter level regulations. In regards to serotonin, norepinephrine, and dopamine, hyperforin has the ability co control these levels – and ultimately controlling one’s mood. (Medline Plus). Does St. John’s wort have any side effects?Research has shown quite a few safety concerns for the use of St. John’s wort. Although this is usually safe for most people when taken over a short term by mouth, it may cause anxiety, irritability, difficulty sleeping, restlessness, strange dreams, a dry mouth, fatigue, upset stomach, skin rash, headache, dizziness, tingling, and diarrhea. In addition, St. John’s wort has a large list of possible side effects when interacting with other drugs and health concerns. This list includes: increasing symptoms of ADHD, possible infertility, develop mania –like symptoms, increase dementia, and complications during surgery.In regards to Ms. Geitl’s medical charts, combining St. John’s wort with birth control pills may increase the breakdown of estrogen and decrease it’s effectiveness. The Zoloft prescription is also not a good combination for St. John’s wort. As this herbal drug increases serotonin levels, antidepressants also increase the levels. When serotonin levels are increased at an extreme level, anxiety, shivering, irritability and heart problems may occur. (Medline Plus) How is St. John’s wort regulated in the US?Within the United States, St. John’s wort may be used for a serious of medical uses and treatments. First, it may be used to regulate neurotransmitters for depression. In addition, a few studies have revealed that St. John’s wort may be used to aid in the reduced dependence of smoking with withdrawal symptoms. Lastly, this has been used for cancer, HIV and Central Nervous System disorders. According to the American Cancer Society, The US Food and Drug Administration does not tightly regulate herbs. Therefore, (unlike prescriptions or OTC medications), the strength or purity can not be guaranteed. It is sold in both drug stores and health food stores in capsule, liquid extract, tea and tablet form. The average dose of St. John’s wort is 300 mg and is taken short term: 3 time per day for 4-6 weeks. (Medline Plus, US Food & Drug Administration, Mayo Clinic, American Cancer Society)How is St. John’s wort used in Europe?In Europe, St. John’s wort is used in a variety of ways – such as treatment for mental disorders, wounds, burns, and for a ‘calm’ or relaxing feeling. In Greece, it is used to fight fevers and evil spirits. In Germany, the agency responsible for regulating herbs – Commission E – has approved St John’s wort as a prescription for the treatment of anxiety, burns, skin lesions, and depression. (American Cancer Society). Specifically in France, St. John’s wort products have been banned by the French health Product Safety Agency because of medication interactions. Additional countries (such as Canada, Japan and the UK) are currently developing drug-herb interaction warning on the product labels. (Medline Plus)Why do you think people are interested in alternative medicine and herbal treatments?I think people are interested in alternative medicine and herbal treatments because of the ‘natural’ and health trends that occur across the country. Research has revealed (to the general public) that its ‘healthier’ to go ‘all natural’ than to put processed items and chemicals into your body. I also think this is of interest because of the inadequate knowledge about medicine. It is often preferred to choose a natural remedy – such as an herb. In the media, we hear about benefits of spices and herbs. Therefore, the thought concept may include: ‘if these are promoted as good for me, then why isn’t St. John’s wort good for me? They’re both a natural herb.’ (American Cancer Society). 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.Weight: 160 lb /2.2 = 72.72 kg Height: 5’11” = 71 inches x 2.54 = 180.34 cm / 100 = 1.80 m BMI: 72.72/(1.8)2 = 22.4 kg/m2(Nelms)Is Ms. Geitl’s recent weight loss anything to be worried about?Yes, her recent weight loss is of concern. According to the National Institute of Mental Health, both weight loss and loss to appetite are both key signs of depression. With a 5 pound weight loss over the course of the past 3 months, it is important to prevent future weight los which could worsen her situation. Depression is not something to take lightly, this weight loss may have just been the beginning to a larger amount of weight loss if the medical professionals hadn’t seen her in enough time. In addition to a lack of energy, her weight loss may be due to various factors – specifically a decrease in energy intake. In order to prevent future weight loss and malnourishment, it is crucial to help Ms. Geitl as soon as possible. (National Institute of Mental Health)Because Ms. Geitl is alert and cooperative, you ask her to complete a Patient- Generated Subjective Global Assessment (PG-SGA) of Nutritional Status. How would you sore her? (See Appendix I). SectionsScoreBox 11Box 25Box 34Box 41Weight loss section (Table 1)3Disease section (Table 2)0Metabolic section (Table 3)0Physical section (Table 4)0Total14SGA Rating: B = Moderately (or suspected of being) malnourishedUsing Appendix 1, how would you triage nutritional intervention?For Ms. Geitl, I would recommend a need for critical improvement and nutritional intervention. As a Registered Dietitian, I would provide nutritional education and helpful meal plan ideas for her to follow. A medical professional would diagnose and treat her properly in response to the depression diagnosis. A therapist could also be helpful for her depression symptoms. What methods are available to estimate Ms. Geitl’s energy needs?Ms. Geitl’s energy needs can be estimated using The Harris-Benedict equation, the World Health Organization estimation, Mifflin St. Joer or the EER calculations (Nelms 241-242). Calculate Ms. Geitl’s basal energy needs using one of the methods you listed in Question 15. Harris Benedict – Women: REE = 655.096 + 9.563W + 1.850 S – 4.676 A Weight = 72.72 kgStature = Height = 180.34 cm Age = 20REE = 655.096 + 9.563(72.72) + 1.850 (180.34) – 4.676 (20)REE = 1,590.62 kcalories(Nelms 241)What is Ms. Geitl’s estimated energy expenditure?PA Coefficient = 1.12 (low active)REE = 1,590.62 kcalories X PA of 1.12 = 1,781.49 kcaloriesGoal Range: 1,700 to 1,800 kcal per day(Nelms 242)Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?Evaluation of her diet history: MEALFOODCaloriesFatCarbProteinCholesterolFiberSodiumCalciumIronbreakfastBlack Coffee, 16 oz000000000lunchDiet Coke, 12 oz0000004000dinnerSalt, 1 dash00000015500dinnerBroccoli, cooked, 1 cup, chopped551114056466dinnerStouffer's Lasagna with Meat & Sauce (party size), 0.5 serving1395139202368120dinnerDiet Coke, 12 oz0000004000dinnerPizza Hut breadstick (1), 1 serving15062040123028dinnerPepper, black, 1 dash000000000PM snackFrozen Yogurt, Yugen Fruz Low Fat Strawberry (Small), 1 serving11000000000HS SnackButtery Flavour Pam (1/8tsp = 0.5g = 1/2 sec spray), 1 serving410000000HS SnackAir popped corn 1/4 cup unpopped, 1 serving131026405000HS SnackSalt, 1 dash00000015500HS SnackDiet Coke, 12 oz0000004000DAILY TOTAL589137021201310922014Evaluation of her 24-hour recall:MEALFOODCaloriesFatCarbProteinFolateCholesterolFiberSodiumCalciumIronbreakfastBlack Coffee, 8 oz0000000000breakfastArnold 100% Whole Wheat Bread, 1 slice110120520315046lunchSoup, chicken noodle, dehydrated, prepared with water, 2 cup11031848190109915lunchSaltine Crackers (Saltines), 2 cracker261412006402lunchDiet Coke, 12 oz00000004000lunchJell-O Strawberry Jello Snack Cup, 1 serving7001710004000dinnerCottage Cheese, 1% Milkfat, 1 cup (not packed)1632628790918142dinnerPeaches, canned, 0.5 cup, halves or slices680181102603dinnerBlack Coffee, 8 oz0000000000Total547 783402028522771918Based on the calculations in from question 16 and 17, Ms. Geitl should consume about 1,700 to 1,800 kcalories per day. Based on her diet history and 24-hour recall, she has not exceeded 600 calories. Therefore, her energy intake is inadequate and poses the concern of malnourishment. For a person of her age, height and weight, she is definitely not consuming enough calories, proteins, carbohydrates and fats. (Information obtained from Case Study Packet)What would you advise?I would strongly advise Ms. Geitl to discuss with her doctor about medicinal treatments, discuss with a therapist in regards to the depression and emotions, and also have a nutrition intervention program with myself, the Registered Dietitian. In my scope of practice, I would encourage her to increase her energy intake and start her meal plan consuming a well-balanced diet – including fruits, vegetables, dairy/calcium products, and protein. By providing her with proper nutritional education and techniques, she would have the tools necessary to make these changes. In addition, if she has food preferences, I could help her determine foods to eat on-campus as well as connect her with the Culinary Support Center for special diet students. Since her diet is overall low in all categories, I would start her off with six smaller meals throughout the day. If possible, I would lastly show her how to make quick and easy foods at home with her friends. Not only would she receive bonding experiences and interactions with others, she can enjoy eating in a reliable and positive environment. List each factor from your nutritional assessment and then determine an expected outcome from each.Assessment FactorExpected OutcomeInadequate energy intakeIncrease energy intake by consuming six small meals per dayInadequate Vitamin & Mineral IntakeIncrease fruit and vegetable intakeInadequate Protein Decrease soda consumption and replace with milkInadequate balanced dietCombine all factors and improve her health - possible meal ideas include : stir fry with veggies, noodles, and preferred meat product; smoothies with protein powder, fruit and leafy greens; omeletWhat is your immediate concern regarding this patient’s use of St. John’s wort?My immediate concern for Ms. Geitl’s use of St. John’s wort includes the following: The Zoloft prescription is also not a good combination for St. John’s wort. As this herbal drug increases serotonin levels, antidepressants also increase the levels. When serotonin levels are increased at an extreme level, anxiety, shivering, irritability and heart problems may occur. In addition, combining St. John’s wort with birth control pills may increase the breakdown of estrogen and decrease it’s effectiveness. Therefore, I would like her to take the Zoloft as prescribed by her physician instead of taking St. John’s wort. Although, I can not suggest or push the patient to do so because this is outside my scope of practice. All I can do is provide the physician with my knowledge and leave the medicinal aspect up to him or her. (Medline Plus) Review the initial nutrition note written for this patient. Is this progress note appropriate? Is it complete? Any errors? Any omissions?This report does provide accurate and appropriate statements – although – it does reflect a few errors. First, the patient has reported a decreased appetite for a duration of 2 semesters. Specifically, she has lost 5 pounds over the past three months. Her diet history indicates 21g protein and her 24-hour recall indicates 550 calories with 40 g protein. In addition to smoking, she consumes about 4-5 servings of alcohol on the weekends. According to my calculations, she needs about 1,700 to 1,800 kcalores per day. While the estimated nutrient needs will be high, I believe that 2,600 kcalories is unrealistic for her at this time. Lastly, her medications not only include Zoloft but OCP as well (birth control). References“About Zoloft.” Zoloft (Sertraline HCL). Pfizer, n.d. Web. 14 Mar. 2014 < of Nutrition and Dietetics (2013).?International dietetics and nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, IL: Academy of Nutrition and Dietetics.“Depression,” National Institute of Mental Health. USA Government, n.d.. Web. 14 Mar. 2014. "Information for Healthcare Professionals: Sertraline (marketed as Zoloft)."?FDA. US Food & Drug Administration, n.d. Web. 14 Mar. 2014. <, Marcia Nahikian.?Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print. "Selective Serotonin Reuptake Inhibitors (SSRIs)."?Mayo Clinic. Mayo Foundation, n.d. Web. 15 Mar. 2014. <. John's Wort. (2008, November 28).Cancer. American Cancer Society. Retrieved March 14, 2014, from . John's Wort. (2012, December 8).?Medline Plus. Retrieved March 14, 2014, from ................
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