Natalie Rohr

KNH 413
Professor Matuszak
Case Study: Drug Nutrient Interaction
1. What is depression?
Depression is a common but serious mood disorder. It causes severe symptoms that affect
how you feel, think, and handle daily activities, such as sleeping, eating, or working.
There are several forms of depression and each are slightly different and develop under
unique circumstances. Some forms of depression include persistent depression (depressed
mood that lasts for at least two years), perinatal depression (depression women
experience after giving birth), psychotic depression (when a person has severe depression
plus some form of psychosis), or seasonal affective depression (onset of depression
during the winter months).
Cited: Depression. (n.d.). Retrieved March 14, 2016, from
https://www.nimh.nih.gov/health/topics/depression/index.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?
When taking Zoloft, there are many side effects that may occur in which nutritional
considerations need to be thought more in depth about. Some symptoms that are rare
include dryness of mouth, acid/sour stomach, decreased appetite, weight loss, stomach
cramps and increased thirst. While there are no nutritional restrictions while taking
Zoloft, Dr. Byrd should frequently ask Ms. Geitl of her side effects while taking the drug
and then relaying that information onto the dietician. If she experiences any of these, she
may not want to eat certain foods or may need increased fluid intake. The dietician and
Ms. Geitl should meet frequently to discuss possible meal plans and dietary requirements.

Cited: Zoloft Side Effects in Detail - Drugs.com. (n.d.). Retrieved March 14, 2016, from
http://www.drugs.com/sfx/zoloft-side-effects.html
3. How do serotonin reuptake inhibitors (SSRIs) work?
SSRIs ease depression by affecting neurotransmitters, which are used to communicate
between brain cells. SSRIs block the reuptake of the neurotransmitter serotonin in the
brain. Changing the balance of serotonin seems to help brain cells send and receive
chemical messages, which in turn boosts mood. SSRIs are called selective because they
seem to primarily affect serotonin, while most other antidepressants may affect other
neurotransmitters as well.
Cited: Depression (major depressive disorder). (n.d.). Retrieved March 14, 2016, from
http://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825
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. Johns 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. Johns wort?
St. Johns wort is a plan that grows in the wild. It has been used for centuries for many
mental health purposes. It may help with some types of depression, similar to treatment
with standard prescription antidepressants, but the evidence is not definitive. If patients
use St. Johns wort, they must be aware of its side effects and its interactions it can have
with other antidepressant drugs. It is also important to note that in the United States, the
Food and Drug Administration has not approved its use as an over-the-counter or
prescription medicine for depression.
Cited: St. John's Wort. (2011). Retrieved March 14, 2016, from
https://nccih.nih.gov/health/stjohnswort/sjw-and-depression.htm

5. How is St. Johns wort used in the United States?

In the United States, the Food and Drug Administration has not yet approved the use of
St. Johns wort as an over-the-counter or prescription medicine for depression.
Cited: St.John'sWort.(2011).RetrievedMarch14,2016,from
https://nccih.nih.gov/health/stjohnswort/sjwanddepression.htm
6. How does St. Johns wort work as an antidepressant?
There are several theories as to how St. Johns wort works. St. Johns wort similarly to an
antidepressant and some research indicates that a chemical called hypericin, located
inside of the plant, is responsible for its antidepressant effects on the brain. More research
says that a chemical called hyperforin helps boost mood neurotransmitters.
Cited: St.John'swort.(n.d.).RetrievedMarch14,2016,from
http://umm.edu/health/medical/altmed/herb/stjohnswort
7. Does St. Johns wort have any side effects?
St. Johns wort is known to affect how the body uses and breaks down a number of drugs
and can cause serious side effects. Combining St. Johns wort with other certain
antidepressants can lead to a potentially life-threatening increase in serotonin levels.
Psychosis is a rare but also possible side effect, especially in people who are at risk or
who have mental health disorders. Taking St. Johns wort can also weaken prescription
medicines such as antidepressants, birth control, some HIV drugs, etc. Other side effects
are usually minor and fairly uncommon and may include upset stomach and sensitivity to
light.
Cited: St.John'sWort.(2011).RetrievedMarch14,2016,from
https://nccih.nih.gov/health/stjohnswort/sjwanddepression.htm
8. How is St. Johns wort regulated in the United States?

St. Johns wort is considered an herbal supplement, which the Food and Drug
Administration does not strictly regulate. It can be purchased over-the-counter in the
United States due to this loose regulation. It is never prescribed to patients experiencing
signs and symptoms of depression.
Cited: St.John'sWort.(2011).RetrievedMarch14,2016,from
https://nccih.nih.gov/health/stjohnswort/sjwanddepression.htm

9. How is St. Johns wort used in Europe?

St. Johns wort is widely used in Europe, especially Germany, as a prescribed herbal
treatment for depression.
Cited: St.John'sWort.(n.d.).RetrievedMarch14,2016,from
http://www.medicalnewstoday.com/articles/174928.php

10. Why do you think people are interested in alternative medicine and herbal
treatments?
I think most people are interested in alternative medicines and herbal treatments because
they believe that these are more natural ways to help cure diseases and sicknesses.
People dont want to put drugs into their body for a potential short period of time and
experience a lot of side effects. While herbal and alternatives medicines may not have as
many side effects as synthetic drugs, people should still be aware that there could be
some, especially associated with different drug interactions.
11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight.
She is 511 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.

71 inches x 2.54 = 180.34 cm

160 pounds / 2.2 = 72.72 kg
12. Is Ms. Geitls recent weight loss anything to be worried about?
Yes, Ms. Geitls recent weight loss should be something of concern. Many side effects of
depression include loss of appetite and poor diet. If she starts taking antidepressants,
these too may have the same side effects. By speaking with the dietician, they can set up
a diet plan for Ms. Geitl to try and get her back on track regarding her weight.
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
Disease section
Metabolic section
Physical section

Score
1
3
1
1
2
0
0
0
Total 8
SGA Rating = moderately (or suspected of being) malnourished
14. Using Appendix I, how would you triage nutritional intervention?
I would triage Ms. Geitls nutritional intervention by requiring that she see a dietitian as
well as a nurse and physician. By doing this, we can be sure that she is getting the
nutrition education she needs as well as making sure her lab values stay within the
normal range.
15. What methods are available to estimate Ms. Geitls energy needs?
There are multiple formulas that can be used in order to estimate Ms. Geitls energy
needs. Mifflin-St. Jeor and The Harris Benedict equation are two of the most common

ways. A quick estimate can also be done to determine her needs, however this is less
accurate than the two previously stated equations.
16. Calculate Ms. Geitls basal energy needs using one of the methods you listed in
Question 15.
Harris Benedict
655 + (9.56 x 72.72 kg) + (1.85 x 180.34 cm) (4.68 x 20)
= 1590 kcal
17. What is Ms. Geitls estimated energy expenditure?
1590 kcal x 1.7 = 2700 2750 kcal
18. Evaluate her diet history and 24-hour recall. Is she meeting her energy needs?
Ms. Geitl is not even close to meeting her energy needs. She needs roughly 1590 kcal a
day (with no activity) and her diet history was roughly 574 calories a day and her 24-hour
recall was 532 calories. In order to meet her energy needs, she would need to triple what
she ate in a day.
19. What would you advise?
I would advise that Ms. Geitl figure out what types of foods she enjoys eating and would
have an appetite for. Since her roommates and her switch off cooking for dinner, maybe
communicate with them the foods she would prefer to eat. Normally I would advise her
to increase her physical activity to initiate hunger and increase her mood, but since she is
so calorie deficient right now, I dont think that would be a good thing to do. She could
try to eat multiple, smaller meals throughout the day that are packed with nutrient dense
foods in order to help increase her caloric intake.
20. List each factor from your nutritional assessment and then determine an
expected outcome from each.
Assessment Factor
Poor appetite

Expected Outcome
May be difficult to increase patients

Low caloric intake each day

24-hour recall: 532 kcal
No food allergies
No previous nutrition education
Roommates purchase some foods
No supplement intake
Regular diet order

calories each day if she does not want to

eat. Seek nutrient-dense and calorie-dense
foods that she enjoys
She will continue to lose weight
She will continue to lose weight
More availability of foods for her to chose
from in order to increase her caloric intake
She has no understanding or knowledge
about nutrition must keep this in mind
when counseling her
Roommates need to be aware and cautious
of her situation
She may develop deficiencies in vitamin
and minerals due to low caloric intake
She will need guidance when constructing
a new diet plan that will be good for her
nutrient- and calorie-dense

21. What is your immediate concern regarding this patients use of St. Johns wort?
My immediate concern with her use of St. Johns wort is the possible drug interactions
that can happen when taking her prescribed antidepressant along with St. Johns wort.
She is currently taking Zoloft and the mixture of these can cause serious and dangerous
side effects such as heart problems, shivering, and anxiety. There is also potential of
dangerous side effects regarding St. Johns wort and her oral contraceptives.
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
The SOAP note was appropriate, however an ADIME note may have been more clear,
precise, and effective. The progress note needed to include that she has lost the 5 pounds
within the past 3 months. The note needed to address possibly starting to take vitamin and
mineral supplements and which ones. The note also needed to include a referral to a
psychologist for counseling of the patients depression and then to wait to do the nutrition
education with the patient until after she has seen a counselor.

References
Depression.(n.d.).RetrievedMarch14,2016,from
https://www.nimh.nih.gov/health/topics/depression/index.shtml
Depression(majordepressivedisorder).(n.d.).RetrievedMarch14,2016,from
http://www.mayoclinic.org/diseasesconditions/depression/indepth/ssris/art
20044825
St.John'sWort.(n.d.).RetrievedMarch14,2016,from
http://www.medicalnewstoday.com/articles/174928.php
St.John'sWort.(2011).RetrievedMarch14,2016,from
https://nccih.nih.gov/health/stjohnswort/sjwanddepression.htm
St.John'swort.(n.d.).RetrievedMarch14,2016,from
http://umm.edu/health/medical/altmed/herb/stjohnswort
ZoloftSideEffectsinDetailDrugs.com.(n.d.).RetrievedMarch14,2016,from
http://www.drugs.com/sfx/zoloftsideeffects.html