Nutrition

Care Conference
Backus Hospital

Brandi Leavitt
Patient Overview
❖ Patient Initials: C.Z.
❖ Age: 19 years old
❖ Gender: Female
❖ Ethnicity: Asian/Hispanic
❖ Admitted to Emergency Room: September 9, 2018
➢ Admitted to Psychiatric Inpatient Unit: September 10, 2018
➢ For: suicide ideation - drank Spic and Span (cleaning supplies)
➢ Mother and girlfriend “forced” her to come
❖ Date Seen: September 12, 2018
❖ Follow up Date: September 13, 2018
Medical Diagnosis & History
❖ Primary Medical Diagnosis: Major Depressive Disorder
➢ Signs and symptoms: depressed, lack of interest, new superficial lacerations on left
thigh and left arm
➢ States: “feels inadequate and not enough for anybody”
❖ Past Medical History
➢ Cannabis abuse
■ Currently: smokes marijuana 2x week, Past: multiple times a day
➢ Alcohol abuse
■ Currently: drinks 2x week, Past: daily
➢ Renal Disorder
➢ *Psychiatric Disorder
➢ *Deliberate self-cutting
➢ *Suicidal behaviors
Major Depressive Disorder
❖ A mood disorder that causes a persistent feeling of sadness and loss of interest.
➢ It affects how you feel, think and behave and can lead to a variety of emotional and physical
problems
➢ Patients may have trouble doing normal day-to-day activities, including a reduce appetite
and weight loss or increased cravings for foods and weight gain.

❖ 16.2 million adults ( > 18 yo) in

the US had at least 1 major
depressive episode in 2016.
❖ Higher in females (8.5%) than in
males (4.8%).
❖ Highest among individuals aged 18
- 25 (10.9%)
❖ Highest among individuals two or
more races (10.5%)

Medical Nutrition Therapy
Major Depressive Disorder
❖ Small, concrete steps and goals/gradual
changes
❖ Assess physical symptoms and changes
❖ Support healthy food choices and eating
habits
❖ Include moderate activity and social
eating
❖ Inquire about history of weight changes
❖ Support blood sugar stability
❖ Ensure adequate folic acid, B12, and
omega-3 FA intake
The Role of Nutrients in Mental Function
*Blood Sugars: poor control → symptoms of
depression
*Omega-3 FA: preferred fatty acid in the brain and
NS, direct influence on serotonin (happy)
* Thiamin (B1): essential coenzyme in glucose
metabolism and the biosynthesis of
neurotransmitters
*Niacin (B2):key component of NADH- important
for the production of dopamine (motivation)
* Vitamin B12: deficiency can cause many mental
symptoms (depression, agitation, impaired
concentration, judgement disorders,)
* Folic Acid: deficiency is associated with
depression, cognitive decline, and dementia
* Vitamin D: affects hundreds of genes in the
human body and is recognized as an important
nutrient for brain health
Anthropometric Data Date

1/6/18
Weight (lb)

102.3

❖ Height: 5’ 7 ½ “ 6/21/18 102.1

❖ Weight: 99.4 lb / 45.2 kg 8/26/18 97.2

❖ BMI: 15.37 kg/m2 = 9/6/18 97.0
underweight
9/9/18 95.0
❖ IBW: 137.5 lbs / 62.5 kg
9/10/19 99.4
❖ UBW: 100 lbs Nutrition Focused Physical Exam
❖ %IBW: 72.3% ❖
Patient alert, originally timid but then became talkative
❖ %IDW: 99.4% ❖
appears extremely tired and “out of it”
❖
Fragile, brittle hair/hair falling out, visible tattoos
❖ % Weight Change: 0.6%
❖
Mild Muscle Wasting: temporalis, clavicle region, scapula
unintentional region and thigh/patella region
❖ Mild Fat Loss: orbital region, check region, triceps region
Social History
❖ Lives at home with Mother and younger brother, girlfriend sleeps over often
❖ Parents never married, no relationship with Father
❖ Dropped out of high school in 9th grade
❖ Per patient: in an abusive relationship with girlfriend who is 4 years older
❖ Low socioeconomic status - family uses SNAP programs and states “there is
limited food in their house”
❖ Mother cooks some meals and girlfriend brings her food to her house
❖ Currently unemployed
❖ Currently unable to drive - crashed her car DUI
❖ Sleeps most of the day (normally wakes up at 3)
❖ Unable to read to time on a clock
Course of Hospitalization
❖ Psychiatric Inpatient Programs/Therapy Sessions 3 - 4x
a day
➢ Individual therapy sessions
➢ Group workshops
➢ Art classes
❖ In the efforts to help CZ with her mental & emotional
status which could ultimately help stimulate her
appetite and encourage more PO consumption
➢ Patient states “she doesn’t want to do anything
besides lay in bed and sleep, including not eating
food”
Biochemical Data
Glucose 91 WNL 65 - 99 mg/dL Stable blood sugars

Calcium 9.0 LOW 9.2 - 11 mg/dL Slightly low -minimal PO →

malabsorption, starvation resulting in low
calcium levels
*Vitamin 500 WNL 243 - 894 pg/mL Deficiency is common in pt with minimal
B12 intake and can cause symptoms of
depression
* Folate 11.3 WNL > 7.2 ng/mL Low levels common in malnourished and
can cause symptoms of depression
* TSH 1.55 WNL 0.27 - 4.20 Nutrition deprivation can cause endocrine
uU/mL complications such as hypothyroidism
Medications
Medication Purpose Side Effect Nutritional Concerns

Prozac Antidepressant Headaches, dizziness, Anorexia, decreased weight

suicidal thinking &
behaviors
Tylenol Analgesic, None applicable Loss of Appetite
(PRN) Antipyretic
Mylanta-Max Antacid, Headaches, fatigue, Decrease abs. of folate
(PRN) Antiflatulent mental/mood changes
Atarax (PRN) Antihistamine, Drowsiness, headaches, Decrease renal function
Antianxiety agitation
Nutrition Needs
❖ Calories:
➢ Mifflin St Jeor = 1520 kcal
➢ kcal/kg: 30 - 35 kcal/kg = 1356 kcal - 1582 kcal
➢ Goal: 1800 kcal/d - for weight gain
❖ Protein:
➢ 1.2 gm/kg - 1.4 gm/kg
➢ 54g Pro - 63g Pro
❖ Fluid:
➢ 1 ml/kcal: 1800 mL/1800 kcal = 1800 mL
➢ 30mL/kg: 30 mL x 45.2 kg = 1,356 mL
➢ Goal: 1500 mL water
❖ Carbohydrates: 50% = 225g CHO
Diet Order
❖ Current: Regular Diet, no sharps (knives, glass, cans), no straws,
paper tray setup (disposable), plastic utensils only

Assessment of Diet Order

❖ Same diet with 3 oral supplements per day to encourage weight gain.
➢ An alternative source of calories and protein if meals are not
entirely consumed.
➢ Patient was compliant with oral supplements.
1 Ensure Enlive with Breakfast (350 kcal & 20g Pro per 8 FL oz.)
Additional: 720
1 Ensure Original Pudding with Lunch (170 kcal & 4g Pro per 4 oz.)
1 Mighty Shake with Dinner (200 kcal & 6g Pro per 4 oz.) kcal & 30g Protein
to diet
Nutrition History Current Intake
❖ Limited Access to Food = low socioeconomic ❖ Poor appetite, lack of
status affects ability to consume adequate meals motivation to eat
❖ Lack of motivation to eat ❖ Currently consumes: 25-50%
❖ Normal Meal Pattern: 1 -2 meals/day (limited meals
choices) ❖ Inadequate caloric, protein,
❖ Main source of food: girlfriend brings her food calcium intake
or takes her to eat ❖ Inadequate fluid intake
➢ Restaurants: McDonalds, Chili’s, Red
Lobster, etc.
❖ Family uses SNAP programs
❖ Nutrition - related knowledge Deficit (basic
food groups)
Diagnosis (PES Statement)
1. Inadequate oral intake RT stress, anxiety and current mental
condition AEB BMI status, patient interview, and lack of
motivation

1. Underweight RT food insecurity AEB patient states family has

limited access to food (use SNAP programs) and current
socioeconomic status
 Intervention Coordination of Care:

1 ❖ Initiate oral supplements (75% intake PO) Discuss with Doctor: oral
❖ Meal structuring/timing/composition for mood supplements, monitor
stability & control Calcium, vit B levels,
❖ Write down goals/plan for consumption folic acid, blood sugars,
❖ Consume 75% meals per day muscle/fat wasting,
❖ Recommend a multivitamin appetite and weight
❖ Recommend weight gain (1-2 lbs per week)
changes, suggest the
❖ Avoid any trigger foods
benefit of stress/anxiety
tools ensure adequate
2 ❖ Provide Education & Handouts: intake, supervision
➢ basic nutrition (food groups & importance of nutrition)
during meals
➢ Alternative methods obtain food & locations (food
banks/pantries/hotlines)
 Continuum of Care:
Monitor/Evaluate * Recommend visit with an outpatient
RD for nutritional counseling &
1❖ Weight change/appetite change education
* Recommend multivitamin
➢ Prozac increased from 10 mg → 20 mg * Recommend continuing oral
❖ PO intake (meals & oral supplements) supplements (if not Ensure, similar to it)
❖ Fluid intake * Recommend discussing with case study
❖ Muscle wasting and fat loss worker about food assistance programs
❖ Patient giving food to others
❖ Lab values: calcium, folate, Vitamin B12, FSH, glucose, CO2 levels
2
❖ Assess ability to name all 5 food groups in MyPlate
❖ Name at least 5 different foods in each category
❖ List at least 3 important reasons for adequate intake
❖ List at least 2 alternative ways to obtain food and their location
Sample Menu
Breakfast Snack Lunch
❖ 3 Scrambled Eggs ❖ 1 C Rice Krispies ❖ Turkey Sandwich with
❖ 1 piece of white toast with Cereal with ½ cup Provolone Cheese, Lettuce,
butter whole chocolate milk Tomato, Mayo on white
❖ 0.5 cup frozen fruit bread
❖ 1 Ensure Enlive Chocolate ❖ 1 Pickle
❖ Ensure Original Pudding
Chocolate

Dinner Snack
Snack
❖ Cheese Burger with Lettuce, ❖ Mighty Shake Chocolate
❖ 10 oz. bag of baked
Tomato, Ketchup
chips
❖ 1 C roasted Asparagus
❖ 1 apple
❖ ½ C mashed potatoes
 - Given that patient is only consuming
Sample Menu Breakdown 25-50% of her daily meals, it assumed
she will not consume the entire suggested
meal plan. Hence, the oral supplements
are recommended to reach the goals of
~1,800 kcal/d and ~60 g Pro/d.
- Oral supplements are calorie and
protein dense and an easier way to
increase calories and protein
consumption per day in the inpatient
facility and at home returning back to
normal routine.
- If consuming the entire meal plan, the
oral supplements should not be needed
since the food alone reached her daily
calorie and protein needs. However, if
consuming less than 100% of meals, oral
supplements are highly recommended for
adequate weight gain, prevent further
weight loss, muscle/fat loss and provide
1 Ensure Enlive Chocolate with Breakfast (350 kcal & 20g Pro per 8 FL oz.) proper nutrients.
1 Ensure Original Pudding Chocolate with Lunch (170 kcal & 4g Pro per 4 oz.)
Additional: 720 kcal &
1 Mighty Shake Chocolate with Dinner (200 kcal & 6g Pro per 4 oz.)
30g Protein to diet
 Thank you!
Any Questions?
 References
❖ Kraus
❖ Food Medications Interactions
❖ Nutrition Care Manual
❖ Nutrition Focused Physical Exam Pocket Guide
❖ Mayoclinic.org
❖ MyFitnessPal
❖ MyPlate
❖ National Institute of Mental Health