Case Study 2

Case Study 2: Drug-Nutrient Interactions
Courtney Pfalzer
Professor Janine Dray
September 21, 2016
Case Study Questions
Usual Diet of Client

Breakfast:
Cold cereal (fortified) or oatmeal
Grapefruit or orange juice
Wheat toast with butter
Coffee with milk
Lunch:
Turkey sandwich on wheat bread with lettuce and tomato
Fresh or frozen berries with cottage cheese
Diet soda or tea

Afternoon snack:
Piece of fruit
Mozzarella cheese stick
Wheat crackers
Dinner:
Broiled Chicken
Brown rice
Asparagus, spinach, or collard greens
Green salad with romaine lettuce and vinaigrette dressing
Fruit sorbet for dessert
Sparkling water, and a glass of wine once or twice weekly
1. What is the Dietary Reference Intake (DRI) for Vitamin K? What is the Daily Value (DV) for
Vitamin K as listed on food and supplement labels?
For women over 19 years of age, an intake of 90g/day of vitamin K is recommended. 1
Meanwhile, the DRI of vitamin K for men aged 19 years or older is 120 g/day .1 The daily value
for vitamin K as listed on most food and supplement labels is 80g/day.2,3
2. Identify sources of Vitamin K, both from diet and synthesis in the body.
Fortified cereals and green leafy vegetables are excellent dietary sources of vitamin K.4 In the
morning, the client consumes either a cold, fortified cereal or oatmeal while in the afternoon,
during lunch, she has a turkey sandwich with lettuce as one of its core ingredients.5 For supper,
the client alternates between the options of asparagus, spinach, or collard greens. She also reports
eating a side salad consisting of romaine lettuce with her dinner as well.5 Vitamin K is also
biosynthesized as vitamin K2 or menaquinone in the gut by intestinal bacteria.6
3. Look up Vitamin K levels of the following sample foods in a food composition table or
database: 1 cup of cooked kale, 1 cup turnip greens, 1 cup raw romaine lettuce, 1 cup raw
peeled cucumber, and 1 cup cooked turnips. How do the Vitamin K levels of these foods compare
to the DRI and DV?
1 cup of chopped, cooked kale that was boiled and drained without any added salt contains
1062.1 g of vitamin K, 1 cup of raw turnip greens contains 138 g of vitamin K, 1 cup of
cooked turnip greens that were boiled and drained without any added salt contains 529.3 g of
vitamin K , 1 cup raw romaine lettuce contains 48.2 g of vitamin K, 1 cup raw peeled cucumber
contains 9.6 g of vitamin K, and 1 cup of cooked turnips that were boiled and drained without
any added salt contains 0.2 g of vitamin K.7,8,9,10,11,12
1062.1 g/ 90 g*100= 1180.1 % DRI1 (Cooked Kale, 1 cup)

1062.1 g/ 80 g*100=1327.6 % DV2,3 (Cooked Kale, 1 cup)
138 g/ 90 g*100= 153.3% DRI1 (Raw Turnip Greens, 1 cup)
138 g/ 80 g*100= 172.5% DV2,3 (Raw Turnip Greens, 1 cup)
529.3 g/ 90 g*100= 588.1% DRI1 (Cooked Turnip Greens, 1 cup)
529.3 g/ 80 g*100= 661.6% DV2,3 (Cooked Turnip Greens, 1 cup)
48.2 g/ 90 g*100= 53.6% DRI1 (Raw Romaine Lettuce, 1 cup)
48.2 g/ 80 g*100= 60.3 % DV2,3 (Raw Romaine Lettuce, 1 cup)
9.6 g/ 90 g*100= 10.7% DRI1 (Raw Peeled Cucumber, 1 cup)
9.6 g/ 80 g*100= 12 % DV2,3 (Raw Peeled Cucumber, 1 cup)
0.2 g/ 90 g*100=.2 % DRI1 (Cooked Turnips, 1 cup)
0.2 g/ 80 g*100= .25% DV2,3(Cooked Turnips, 1 cup)
4. What is the recommended adjustment in Vitamin K intake in patients on warfarin? What
foods should they avoid or limit?
For patients prescribed warfarin, it is important that they keep their intake of vitamin K
consistent to ensure the drug works properly.13 An excess of vitamin K could lessen the effects of
warfarin while a sudden decrease in vitamin K intake could potentiate its effects.13 Avocadoes,
onions, garlic, grapefruit, grapefruit juice, cranberry, papaya, mango, all forms of alcohol, and
foods generally very high in vitamin K (i.e. kale, turnip greens, green tea) have the potential to
counteract the effects of warfarin and/or alter drug metabolism and PT/INR.13 Because of this, it
is generally recommended that these foods either be limited or fully avoided (i.e. alcohol,
grapefruit/grapefruit juice, cranberry juice) to prevent food-drug interactions.13
5. Is it advisable for her to take a multivitamin? How much vitamin K is in a standard
once daily multivitamin?
Patients are advised to contact their doctor if they are taking a multivitamin while prescribed
warfarin.13 Because multivitamin and multimineral supplements have no standard scientific,
regulatory, or marketplace definitions, products may contain levels of nutrients that are much
higher than the recommended amounts for the DRIs and DVs, which can prove dangerous if the
counteractive effects of vitamin K on warfarin are taken into account. 14 For example, the
multivitamin One A Day Womens provides 25 g of vitamin K, while Vitacost Synergy Once
Daily provides 300 g of vitamin K, and Alive! Once Daily Ultra Potency provides 80 g of
vitamin K .15,16,17
6. How would her periodic use of antibiotics affect her INR?
Antibiotics such as Bactrim can potentiate the effects of warfarin and raise INR, which
significantly increase the risk of bleeding.18,19 Bactrim interacts with warfarin by inhibiting the
intestinal bacteria that synthesize vitamin K and the cytochrome p450 isozymes which are
involved in the hepatic metabolism of warfarin. 18,19
7. Describe the effects of herbal supplements such as St. Johns wort on medication action.
St. Johns wort reduces the efficacy of medication action by inducing enzymes involved in drug
metabolism such as Cytochrome P450 3A4, Cytochrome P450 2D6, Cytochrome P450 1A2, and
p-glycoprotein.13 Induction of these enzymes increases drug metabolism and decreases serum
drug levels.13
8. Name other food medication interactions for which she is at risk.
In a record of her usual diet, the client indicated that she consumes either orange or grapefruit
juice as a beverage in the morning.20 She also stated that she enjoys a glass of wine once or twice
weekly.20 Both grapefruit and grapefruit juice potentiate the effects of warfarin by inactivating
intestinal cytochrome P450.21 This results in presystemic metabolism being reduced and oral
drug bioavailability being increased.21 Grapefruit has also been found to interact with HMG-CoA
reductase inhibitor, simvastatin, another medication prescribed to the client.21 Alcohol alters
metabolism of warfarin and PT/INR levels.13 Chronic alcohol abuse increases drug metabolism
and lowers PT/INR while acute intoxication decreases drug metabolism and raises PT/INR.13
9. Write a PES statement. What is your intervention?
Inadequate vitamin K intake related to inappropriate food choices as evidenced by an INR of 4.0
seconds.20 I would counsel the client on her current food options and explain what foods and
supplements she needs to limit or avoid in order to maintain a normal INR. I would also
encourage her to cease taking a multivitamin because it might interfere with the consistency of
her vitamin K intake.20 Id then advise the client to consult her physician about her current and
past prescribed medications to ensure that she is not undergoing any drug interactions.
10. Name a specific intervention(s) that would address her nutrition diagnosis, and specify how
you would monitor their effectiveness. In addition to diet and fluid status, what other parameter
might you monitor in a HF patient?
Nutrition counseling as a means of improving current food choices and the cessation of taking a
multivitamin supplement are two specific interventions that would address the clients nutrition
diagnosis. To monitor their effectiveness, I would meet with the client on a weekly basis to
discuss her food choices, current INR levels, and medication usage. I would also encourage the
client to continue recording her food intake in a journal to oversee any dietary changes she made
following my suggestions.1 In addition to diet and fluid status, another parameter that I would
monitor in a HF patient would be B-natriuretic peptide levels.22 Krauses Food and the Nutrition
Care Process states, BNP is secreted by the ventricles in response to pressure and is predictive
of the severity of HF and morality of any level of BMI.22 Elevated BNP is commonly seen in
patients diagnosed with HF (>100 pg/mL is considered abnormal).22 Monitoring BNP levels can
determine if heart failure symptoms are worsening or improving.22
References
1. Nelms MNN, Lacey K, Sucher K. Nutrition therapy and Pathophysiology - 2nd edition. 2nd
ed. Belmont, CA, United States: Wadsworth, Cengage Learning; 2011.
2. Guidance for Industry: A Food Labeling Guide (14. Appendix F: Calculate the Percent Daily
Value for the Appropriate Nutrients). U.S. Food and Drug Administration website.
http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Labe
lingNutrition/ucm064928.htm. Accessed September 17, 2016.
3. Daily Value. National Institutes of Health Dietary Supplement Label Database website.
http://www.dsld.nlm.nih.gov/dsld/dailyvalue.jsp. Accessed September 17, 2016.
4. Vitamin K. U.S. National Library of Medicine MedlinePlus website.
https://medlineplus.gov/ency/article/002407.htm. Accessed September 17, 2016.
5. Emery EZ, Emery LZ. Clinical case studies for the nutrition care process. Burlington, MA,
United States: Jones and Bartlett Publishers; 2012.
6. Conly JM, Stein K. The production of menaquinones (vitamin K2) by intestinal bacteria and
their role in maintaining coagulation homeostasis. Progress in Food and Nutrition Science
Journal. 1992; 16 (4): 307-43.
7. Basic Report: 11234, Kale, cooked, boiled, drained, without salt. United States Department of
Agriculture Agricultural Research Service National Nutrient Database for Standard Reference
Release 28 website. https://ndb.nal.usda.gov/ndb/foods/show?
ndbno=11234&fg=11&man=&lfacet=&format=Abridged&count=&max=25&offset=175&sort=f
&qlookup=&rptfrm=nl&nutrient1=430&nutrient2=&nutrient3=&subset=0&totCount=531&mea
sureby=m. Accessed September 17, 2016.
8. Basic Report: 11568, Turnip greens, raw. United States Department of Agriculture
Agricultural Research Service National Nutrient Database for Standard Reference Release 28
website. https://ndb.nal.usda.gov/ndb/foods/show?
9. Basic Report: 11569, Turnip greens, cooked, boiled, drained, without salt. United States
Department of Agriculture Agricultural Research Service National Nutrient Database for
Standard Reference Release 28 website. https://ndb.nal.usda.gov/ndb/foods/show?
10. Basic Report: 11251, Lettuce, cos or romaine, raw. United States Department of Agriculture
11. Basic Report: 11206, Cucumber, peeled, raw. United States Department of Agriculture
12. Basic Report: 11565, Turnips, cooked, boiled, drained, without salt. United States
Department of Agriculture Agricultural Research Service National Nutrient Database for
Standard Reference Release 28 website. https://ndb.nal.usda.gov/ndb/foods/show?
13. Pronsky ZM, Elbe D, Ayoob K. Food Medication Interactions 18th ed. Birchrunville, PA,
United States: Food-Medication Interactions;2015.
14. Yetley E. Multivitamin and multimineral dietary supplements: Definitions, characterization,
bioavailability, and drug interactions. The American Journal of Clinical Nutrition.
2007;85(1):269S-276S.
15. ONE A DAY Womens. Bayer Healthcare Consumer Care website.
https://labeling.bayercare.com/omr/online/oad-women.pdf. Accessed September 18, 2016.
16. Vitacost Synergy Once Daily Multi-Vitamin. Vitacost website.
http://www.vitacost.com/vitacost-synergy-once-daily-r-multi-vitamin-30-capsules-1?
isrc=home:carousel1:pos2:844197016129. Accessed September 18, 2016.
17. Alive! Once Daily Ultra Potency. Natures Way website.
http://www.naturesway.com/Product-Catalog/Alive-Once-Daily-Ultra-60-Tabs. Accessed
September 18, 2016.
18. Ament PW, Bertolino JG, Liszewski JL. Clinically Significant Drug Interactions. American
Family Physician. 2000;61(6):1745-1754.
19. Baillargeon J, Holmes HM, Lin Y, et al. Concurrent Use of Warfarin and Antibiotics and the
Risk of Bleeding in Older Adults. American Journal of Medicine. 2012;125(2): 183-189.
20. Emery EZ, Emery LZ. Clinical case studies for the nutrition care process. Burlington, MA,
United States: Jones and Bartlett Publishers; 2012.
21. Bailey DG, Dresser GK. Interactions between grapefruit juice and cardiovascular drugs.
American Journal of Cardiovascular Drugs. 2004;4(5):281297. doi:10.2165/00129784200404050-00002.
22. Mahan KL, Escott-Stump S, Raymond JL, L. Kathleen Mahan MS RD CDE, Sylvia EscottStump MA RD LDN, Janice L Raymond MS RD CD. Krauses food & the nutrition care process
(Krauses food & nutrition therapy). 13th ed. Philadelphia, PA, United States: Elsevier Health
Sciences; 2012.

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Case Study 2: Drug-Nutrient Interactions

Case Study Questions

Usual Diet of Client

Diet soda or tea

1062.1 g/ 90 g*100= 1180.1 % DRI1 (Cooked Kale, 1 cup)

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