- What is depression?
Depression is a clinical disorder that results in someone feeling sad, at loss, angry, or frustrated. The exact cause is unknown but has been linked to a possible chemical change in the brain. Regardless of cause, the result is a feeling of worthlessness, isolation, thoughts of suicide, and distorted views on oneself. It can also result in fatigue and lack of motivation. In order to be classified as depression, the symptoms must affect a person’s daily life over an extended period of time.
Source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/
- 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?
Zoloft should not be consumed with alcohol (this is important to note as Ms. Geitl is a college student who is of age), and should not be taken in combination with certain herbs, including St. John’s wort unless approved by the physician. Vitamin D is also typically taken with Zoloft in those patients with depression.
Source: http://www.naturalnews.com/DrugWatch_Zoloft.html
- How do serotonin reuptake inhibitors (SSRI’s) work?
SSRI’s are the most commonly prescribed medication for those with depression, as it changes neurotransmitters that communicate between brain cells. They work by blocking the reabsorption of serotonin, and this altered chemical balance helps the brain cells send and receive chemical messages in a manner that has been proven to boost mood, and in turn lessens the symptoms of depression.
Source: http://www.mayoclinic.com/health/ssris/MH00066
- During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals, or herbal supplements. She tells you her mother suggest she try Hypericum perforatum (St. John’s wort) because in Germany it is prescribed to treat depression. Ms. Geitl did as her mother suggester, as it is available without prescription in the United States. What is St. John’s wort?
St. John’s wort is a yellow flowered plant which was discovered to contain chemicals that have medicinal effect. It can be used to treat depression, anxiety, or sleep disorders but can also interact with other medications. It should only be taken with other medications under a physician’s supervision.
Source: http://nccam.nih.gov/health/stjohnswort
- How is St. John’s wort used in the United States?
The flowering tops of this herb are used in preparing teas, tablets, and capsules for medicinal use. In the United States, there is some interest in the public on using St. John’s wort to treat depression (as herbs and natural supplementation has become increasingly popular), but the USDA does not approve St. John’s wort as a treatment of depression as there has not been enough research done on the topic.
Source: http://nccam.nih.gov/health/stjohnswort
- How does St. John’s wort work as an antidepressant?
The flower’s ability to relieve depression is not fully understood. There are studies that suggest an effect on serotonin and dopamine levels in the brain. Some studies suggest the possibility that St. John’s wort may prevent nerve cells in the brain from reabsorbing serotonin (similar to the way Zoloft works). While some studies have attributed the effects on an ability to reduce the levels of protein involved in the body’s immune system.
Source: http://nccam.nih.gov/health/stjohnswort
- Does St. John’s wort have any side effects?
Side effects include anxiety, dry mouth, dizziness, diarrhea, nausea, fatigue, increased sensitivity to light, headache, confusion, and sexual dysfunction.
Source: http://nccam.nih.gov/health/stjohnswort
- How is St. John’s wort regulated in the United States?
St. John’s wort is not regulated in the United States, as it is classified as a dietary supplement.
Source: http://www.anxietydepressionhealth.org/st-johns-wort-hypercium.htm
- How is St. John’s wort used in Europe?
In Europe, St. John’s wort is widely used as an aid in depression, anxiety, and sleep disorders though it is typically only available through prescription. In Germany specifically, it is prescribed more often than Prozac (a popular antidepressant in the United States and Europe alike). Other uses for St. John’s wort include the treatment of bronchial inflammation, bed-wetting, stomach problems, insomnia, migraines, kidney disorders, hemorrhoids, hypothyroidism, and malaria.
Source: http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMe dicine/HerbsVitaminsandMinerals/st-johns-wort
- Why do you think people are interested in alternative medicine and herbal treatments?
There is a new push in the market for “organic” and “natural” products because of the use of chemicals and pesticides in the country. I assume that this push is impacting not only people’s perceptions on food but on other chemicals as well. For example, growing up my mom would never let us take medications unless it was absolutely necessary because of the idea that being as close to “natural” and nature as possible is healthier. Herbs are natural and consumers can see what goes into them, while medications have an array of ingredients created in a lab with names that can’t be pronounced. Today’s society is taught that they should know what they are putting into their body. Organic products in the supermarket allow this in respect to food while herbs allow this on the medicinal level.
Source: Cami Gilman
- 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 = 72.72kg
Height: 71in. x 2.54 = 180.34cm = 1.8m
- Is Ms. Geitl’s recent weight loss anything to be worried about?
Ms. Geitl has had a recent weight loss of five pounds. This loss does not place her in the category of severely malnourished, which is a loss of greater than 10% UBW. However, her weight loss will become a concern if it continues. The cause of her weight loss is depression and therefore, the priority is to treat the underlying cause. Some nutrition education and encouragement to eat may also be necessary, but ideally Ms. Geitl will begin to eat more regularly when her depression subsides.
Source: Cami Gilman
- 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 score her?
| Sections | Score |
| Box 1 | 1 |
| Box 2 | 1 |
| Box 3 | 1 |
| Box 4 | 3 |
| Weight loss section (Table 1) | 0 |
| Disease section (Table 2) | 0 |
| Metabolic section (Table 3) | 1 |
| Physical section (Table 4) | 0 |
| Total | 7 |
- Using Appendix 1, how would you triage nutritional intervention?
Ms. Geitl’s triage point score is about a 2-3, meaning that education is the primary intervention. This can be done by a dietician, nurse, or clinician. If weight loss progresses so much that her triage score becomes a 4-8, a more aggressive intervention will need to be implemented and this would include a team approach that would include a dietician in conjunction with a nurse or physician.
- What methods are available to estimate Ms. Geitl’s energy needs?
Several acceptable methods exist when estimating one’s energy needs. These methods include the Mifflin-St. Jeor formula, the Harris-Benedict equation, the Quick Estimate equation, and the WHO (World Health Organization) equation. Some take into account different factors, but all are good estimations on caloric needs.
- Calculate Ms. Geitl’s basal energy needs using one of the methods you listed in Question 15.
Mifflin-St. Jeor: 10 x wt (kg) + 6.25 x ht (m) – 5 x age (yrs) – 161
10 x (72.72) + 6.25 x (180.34) – 5 x (20) – 161 = 1,593 = 1,500-1,600 kcal/day
- What is Ms. Geitl’s estimated energy expenditure?
EER: 354 – 6.91 x age + PA x (9.36 x wt + 726 x ht)
354 – 6.91 x (20) + 1.12 x (9.36 x (72.72) + (1.8034))
= 2,287 kcal or 2,200-2,300 kcal/day
Protein (15%): 2,287 x .15 = 343.125 / 4 = 86 grams
Fat (25%): 2,287 x .25 = 571.75 / 9 = 64 grams
Carbohydrates (60%): 2,287 x 1,372.8 / 4 = 343 grams
- Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?
According to her 24-hour recall in particular, Ms. Geitl has consumed about 650/700 kcals consisting of 12g total fat, 88g carbohydrates, and 52 grams of protein. Her overall diet history seems to have a similar dietary pattern. You can see above that the recommended dietary intake for someone Ms. Geitl’s height, weight, and age. This includes at least 2,200 kcals per day and 86 grams of protein, 64 grams of fat, and 343 grams of carbohydrates. Therefore, she is not meeting her energy needs.
Source: My Fitness Pal iPhone Application
- What would you advise?
I would advise Ms. Geitl to consume three meals and three snack each day. Each meal and snack should include some form of each macronutrient (carbohydrate, protein, and fat). I would emphasize the importance of her nutritional health as it may also be contributing to her depression. If her body was better nourished, she may get some of her energy back and sleep better. I would also recommend a multivitamin that had vitamin D and talk to her about different foods that are good sources of vitamin D, because of the drug-nutrient interaction of zoloft.
- List each factor from your nutritional assessment and then determine an expected outcome from each.
| Assessment Factor | Expected Outcome |
| Inadequate caloric intake | Increase caloric consumption by ensuring three full meals each day with snack in between. These meals should be nutrient dense, and this will stop the weight loss which may be in part contributing to depressive symptoms. |
| Inadequate Fat intake | Increase fat intake. Fat-soluble vitamins A,D,E, and K are most likely not being properly absorbed as they need fat in order to do so. Focus on good fats from nuts, seeds, fish, and olive oils. |
| Inadequate Protein intake | Increase protein intake so prevent continued muscle wasting. This should be done via meat products with good fats as well as protein-rich plant sources (beans, nuts, soy). |
| Low Vitamin D intake | Increasing vitamin D intake through a multivitamin as well as a natural sources will help with depressive symptoms and also aid in the drug’s antidepressant effects. |
- What is your immediate concern regarding this patient’s use of St. John’s wort?
Initially, my concern was a drug-herbal interaction or overdose if taken with the SSRI antidepressant Ms. Geitl was prescribed. After more research, I was also concerned with the possibility of it getting in the way of protein absorption as Ms. Geitl is already at risk of becoming malnourished.
- Review the initial note written for this patient. Is this progress note appropriate? Is it complete? Any errors? Any omissions?
The initial note written for Ms. Geitl was no appropriate – incomplete and had some errors and omissions in it. Overall, I prefer the ADIME method. In the subjective data, the total number of kcal and protein should have been included from the diet history and 24-hour recall. Though you can guesstimate that the patient is not eating enough, an exact number is necessary in order to show just how far off the patient is. Also omitted was the patient’s alcohol consumption – which is essential in knowing whether or not to educate the patient on consuming alcohol safely if she does choose to do so, and the importance of not taking her medications when consuming alcohol. Also omitted was religious background which may be important if there are dietary restraints based on religious beliefs. Objective data was also omitted. The conversion of metric height and weight were not there (which is important as this patient is an international student) and are essential for understanding. Also omitted was the gender of the patient, temperature, pulse, blood pressure, respiration rate, medical diagnosis, and current medical care. There was also no PES statements which are essential in the approach to a nutrition i
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