Nutrition and Mental Health

Leigh Wagner MS, RD

KU Integrative Medicine

KU Integrative Medicine

Nutrition and Integrative Medicine

• Personalized medical nutrition therapy and treatment of chronic disease that embraces conventional and complementary therapies.

• Integrative and functional nutrition reaffirms the importance of the therapeutic relationship, a focus on the whole person, lifestyle, biochemical (metabolic) individuality and environmental influences.

• Emphasizes “Food as Medicine”.

Nutrition Program at KU IM

Nutrition Counseling Healing Foods Kitchen

• Individualized nutrition assessment

• Nutrition physical exam

• Body composition analysis

• Laboratory testing

• Food sensitivities

• Cancer, Digestive Issues, Autoimmune diseases, Metabolic problems

• Cooking classes for beginners and some intermediate-level home chefs.

• KU Med Center Campus – Integrative Medicine

• Afternoons

• $15-25 – depending on menu

Individualized Nutrition Assessment

• Assessment (1.5 hours):

• Many chronic medical conditions are related to nutrition

• IM explores underlying causes for illness & disease that are unique to each individual

• Example: High blood pressure - one problem, multiple causes

• Genetics/family history, hypercholesterolemia

• Ethnicity: African American, Latino, Caucasian (different risk)

• Toxins, smoking, organ problems/renal

• Nutrition – salt sensitivity, CAD, potassium, magnesium..

Presentation Objectives

After this discussion, attendees should be able to… • Describe reasons nutrition is important to mental

health.

• Discuss key nutrients necessary to biochemical and mental wellness/balance.

• Identify nutritional needs that may be different based on whether his/her patient is physically well vs. those with co-morbid illness such as diabetes, cancer or heart disease.

• Describe the basics of screening for patients/clients that may be need detailed nutritional consultation.

Food As Medicine

• Consume 3+ times daily

• Foods, beverages speak to our bodies – Organs, tissues, cells, DNA…

• What messages do you want to send to your bodies?

• The beauty of it… our bodies are innately designed to heal themselves when given the right fuel

• Accounting for the nuances of our family history – genetics

• Using Food As Medicine…

What is “Good Nutrition”?

Food Processing

The Basics of Healthy Eating

• General basics of healthy nutrition lifestyle:

Whole, minimally-processed foods: Vegetables, fruit, meat/seafood/poultry, beans, nuts/seeds, dairy (when tolerated), fats/oils, eggs, grains (when tolerated)

These foods are what our bodies are made to run on!

KU Healing Foods Kitchen

Populations vs. Individualized Care

• Every person in this room has a unique nutrition status

• Public nutrition information is general and based on large, epidemiologic studies

• Individualized nutrition counseling tailors care to the individual…our Biochemical Individuality

The Dietitian’s world… Biochemistry

Membrane Phospholipids

Series 4 Leukotrienes Prostaglandins Series 2

Thromboxanes A2, B2

Arachidonic Acid

Phospholipase A2

Vitamin E, Quercitin

Licorice, Turmeric

Corticosteroids

Ginger, turmeric, Black

Williow, Wintergreen

EPA & DHA

5-Lipoxygenase (LOX)

Cyclooxygenase 2 (COX)

Cycooxygenase 1 (COX)

12-Lipoxygenase (LOX)

NSAIDS

Sulfasalazine

Turmeric, Onion, Garlic, Boswellia

Vit E, Quercitin, EPA

Formation of Neurotransmitters

Dopamine β-Hydroxylase Vitamin C, COPPER, O2

Formation of Neurotransmitters

L-Amino Acid Decarboxylase

PLP (Vitamin B6)

Nutrition on a Spectrum

Chocolate-Covered

Granola Bar

Granola Bar

Whole Food Bar

Fruit + Handful

Nuts

Where are you now…?

Candy Bar

Mental and Emotional Health and working with a Nutritionist

• Guilt • Shame • Doubt/Lack of self-efficacy • Depression, Anxiety • Motivations • Nutritional history (childhood, adolescence,

adulthood) • Emotional eating Intuitive Eating • May first need to focus on specific, Biochemical

balance

Environment

Lifestyle

Genetics

Your Health

Nutrition in Integrative Medicine

Food and Nutrition

Mind

Spirit Body

Your Top 3 Priorities

List the most important

things in your life…

Take a Moment

• Write down everything you ate, drank, medications, supplements…

• Since you woke up yesterday until bed last night

• Without judgment

• Honesty with oneself promotes health

• This gives you an idea of where you may be on the spectrum.

• Where do you WANT to be?

Past National Nutritional Guidelines

New National Nutritional Guidelines

You are what you EAT?

You are what you CAN ABSORB!

IDU: Nutrition Assessment Tool

• Ingestion: Food, Beverages, Supplements

• Digestion: Assess GI Tract from Mouth to Anus

• Utilization: GI; Lab Evidence; Nutrition Physical

Structure = Function

Table adapted from: http://faculty.washington.edu/chudler/facts.html#brain

Composition of Brain

Whole Brain (%)

Water 77-78%

Lipid 10-12%

Protein 8%

Carbohydrate 1%

Soluble Organic Substances

2%

Inorganic Salts 1%

Reference: McIlwain H, Bachelard HS. Biochemistry and the Central Nervous System, Edinburgh: Churchill Livingston, 1985

Mental Health & Nutrition

Bystritsky et al, 2012

Dynamic models describe mental processes and phenomena that change over time,

more like a movie than a photograph, with multiple variables interacting over time.

“Non-linear dynamical psychiatry”

Bystritsky et al, 2012

Nutrition is also non-linear

B-vitamins are required for proper functioning of the methylation cycle, monoamine production,

DNA synthesis, and maintenance of phospholipids such as myelin.

Fat-soluble vitamins A, D and E play important roles in genetic transcription, antioxidant

protection.

Resources

The PsychoNutriologic Person

Nutritional status and mental health/mental illness are often interrelated in ways that can be assessed and treated for improvement of

health and quality of life.

Leyse-Wallace

Stages of Nutritional Injury

Conceptual Model adapted with permission from work of Guillermo Arroyave

Stages of Nutritional Injury

Adapted with permission from Guillermo Arroyave. Arroyave G. Genetic and Biologic Variability in Human Nutrient Requirements. Young R &

Scrimshaw NS. American Journal of Clinical Nutrition, 1979; 32:486-500.

Stage 0

Examples of conditions:

Family history of diabetes,

alcoholism, celiac disease, bipolar

disease

Stage 1 and 2

Omits food groups due to

allergies and/or preferences

Eats 1 meal/day

Use mega-dose supplements

Fad diet use

Stage 3

Wt gain/loss in

past 3-6 months

High Chol, Glu, Hcy

Relevant score on ED

assessment

Stage 4

Fatigue

Headaches

Irritability

Trouble concentrating

Oral lesions

Nausea

Diarrhea

Poor appetite

Stage 5

Metabolic

Syndrome

Bulimia

Gestational

diabetes

Alcohol

dependence

Medication with Nutrient-Drug

interaction

Stage 6

Bariatric surgery

Dementia

Phenylketonuria

Xerosis with

ulceration

Vit-A blindness

Pernicious anemia

Examples of nutrients:

Regular alcohol intake,

Pro. Carb

Vit A,D, Fol, E, C

Iron, CA

Low Fol, Vit B12, C

Iron, Ess. Fatty Acids

Hi Trig,Chol, Hcy

B-Vit deficiency

Low carb intake

Insufficient or excess

Calorie intake

Low Vit, Min intake

MAOI Medication

Lactose intolerance

Vit B12, A

Phenylalanine

Healthy or

Possible Risk of

Nutritional

Injury

(Genetics:Genotype

Host: Phenotype

Environment:

Agents)

Stage I

Diminishing

Reserves/

Building Excess

Stage II

Reserves

Exhausted

Stage III

Physiologic

and Metabolic

Alterations

Stage IV

Nonspecific

Signs and

Symptoms

Stage V

Illness

Stage VI

Permanent

Damage

Leyse-Wallace

Stages of Nutritional Injury:

Risk of Nutritional Injury – genes, habits

Stage I: Diminishing reserves; building excesses

Stage II: Reserves exhausted

Stage III: Physiologic/Metabolic Alteration

Stage IV: Non-specific Signs/Symptoms

Stage V: Illness

Stage VI: Permanent damage

Leyse-Wallace

Patients/Clients at Highest Nutritional “Risk”

1. Absorption (“Utilization”) problems Bariatric Surgery (Stage III) IBD (Stage III)

2. Bipolar Disorder (Stages I & II) 3. Food-insecure (Stages I & II) 4. Alcohol, Drug Abuse 5. Restrictive diets Veganism, eating disorders,

low/no carbohydrate, orthorexia (Stage I & II) Elevated risk for nutritional deficiencies. We’re also

addressing nutritional insufficiencies

Leyse-Wallace, 2008

Bariatric Surgery (Stage III)

Two year follow-up, after Roux-en-Y surgery;

Rx for a standard multivitamin supplement designed for this group

Follow-ups to determine need for addition supplements.

• At 3 months 34% needed at least one additional specific supplement;

• At 6 months 59% needed additional supplementation

• At 24 months 98% needed additional supplementation

Gastygear, Christopher,e t al. Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation. Am J Clin Nutr 2008; 87(5)1128-1133.

Ruth Leyse-Wallace PhD, RD

Bipolar Disorder (Stages I & II)

Individuals with Bipolar Disorder were more likely to:

• Eat fewer than two meals a day

• Have difficulty obtaining or cooking food.

• Have gained ≥ 10 lbs over past 6 months

• Have poor exercise habits, and

• The least likely to report that their health care provider had discussed their eating habits or exercise habits

Kilbourne, AM, et al. Nutrition and exercise behavior among patients with bipolar disorder. Bipolar Disord 2007; 9(5):443-452.

Ruth Leyse Wallace PhD, RD

Walsh’s “Repeat Offenders”

• Copper overload

• B6 Deficiency

• Zinc Deficiency

• Methyl/folate imbalances

• Oxidative stress overload

• Amino acid imbalances

Walsh, 2012

Copper Overload

Biochemical Manifestations

• Lower dopamine and increase norepinephrine in brain

Walsh, 2012

Dopamine β-Hydroxylase Vitamin C, COPPER, O2

Copper Overload

Clinical Manifestations (associated with)

• Paranoid schizophrenia

• Bipolar disorder

• Postpartum depression

• ADHD

• Autism

• Violent behavior

Walsh, 2012

Vitamin B6 Deficiency

Biochemical Manifestations

• Poor formation of dopamine, GABA, serotonin

• Participates in over 80 biochemical reactions in the body

Walsh, 2012

L-Amino Acid Decarboxylase

PLP (Vitamin B6)

Vitamin B6 Deficiency

Clinical Manifestations

• Irritability

• Depression

• Short-Term memory

• Psychosis

Overdose: Neuropathy (reversible), vivid dreams

Combs, 2008 (Walsh, 2012)

Zinc Deficiency

Biochemical Manifestations: • Decreases protection from oxidative stress • Alters/inhibits conversion of B6 PLP (needed

for GABA, serotonin, dopamine) • Copper/Zinc balance Zn Functions: • Component of BBB • Cofactor for ~100 different enzymes • Important for production of melatonin

Walsh, 2012 United States DRIs Digirolamo et al. 2009

Zinc Deficiency Clinical Manifestations

• ↓ Zinc in pts dx with: Depression, behavior disorders, ADHD, autism, schizophrenia

• Growth retardation

• Alopecia

• Diarrhea

• Delayed Sexual Maturation, Impotence

• Eye, skin lesions

• Impaired appetite

Walsh, 2012 United States DRIs

Zinc Deficiency

• 25 mg Zn/day supplementation significantly lowered depression scores after 6 and 12 weeks with standard antidepressant therapy

– Versus placebo group of only antidepressant

– Zinc may improve symptoms of depression in those treated with antidepressants

Digirolamo et al. 2009

Methyl/folate imbalances

Biochemical Manifestations

• Folate deficiency: reduced production of transporters and elevated synaptic activity – Folic acid: reuptake enhancer that combats

excessive dopamine activity

• Under-methylation: excessive gene expression of transporters and reduced synaptic activity – SAMe: Natural reuptake inhibitor for serotonin,

dopamine, and norepinephrine

Walsh, 2012

Methyl/folate imbalances

Clinical Manifestations

• Schizophrenia

• Bipolar disorder

• Depression

• Anxiety

• Autism Spectrum Disorders

– Developmental delays linked with malfunctioning folate transportation to CNS (Main et al. 2010)

Walsh, 2012

Genetic Variants

• Catechol-O-methyltranferase (COMT)

– Modulator of dopamine levels

– Polymorphic variants associated with schizophrenia, bipolar disorder, and anxiety disorder

• 2 SNPs linked with depression

• 1 SNP associated with depression and anxiety symptoms in young children

Hatzimanolis et al, 2013 Sheik et al, 2013

Oxidative stress overload

Biochemical Manifestations

• Elevated urine pyrroles

• Low plasma zinc and PLP

• Depressed serum glutathione

• Elevated non-ceruloplasmin serum copper

Walsh, 2012

Oxidative stress overload

Clinical Manifestations

• Elevated pyrrole levels associated with: ADHD, Behavioral Disorder, Autism, Depression, Bipolar Disorder, Schizophrenia

– Symptoms: high anxiety, frequent moods swings, poor short-term memory, reading disorder, morning nausea, absence of dream recall, frequent anger and rages

Walsh, 2012

Amino Acid Imbalances

Biochemical Manifestations

• Altered synthesis of

– Serotonin (tryptophan)

– Dopamine and norepinephrine (Phe, Tyr)

– GABA (Gln)

– Histamine (Histidine)

– SAMe (Met)

Walsh, 2012

Amino Acid Imbalances

Clinical Manifestations

• Anxiety

• Depression

• Psychosis

• ADHD

Walsh, 2012 Gaby, 2011

Epigenetics and Mental Health

• Endocrine Disrupting Chemicals (EDCs)

– “alters hormonal and homeostatic systems that enable the organism to communicate with and respond to its environment”

– Synthetic (plastics) and natural (phytoestrogens)

– Dopamine, norepinephrine, serotonin, and glutamate are sensitive to endocrine disruption

• Affecting cognition, learning, memory, and other behaviors

– May also affect subsequent generations

(Diamanti-Kandrakis et al, 2009)

NUTRITION AND DIAGNOSIS-RELATED CARE

Evidence versus Harm Grading Icons

• Integrative Medicine by Dr. David Rakel (U. Wisconsin Family Medicine)

Most efficacious and safest

Least efficacious and highest risk for harm

Evidence versus Harm Grading Icons

• Dietitians in Integrative and Functional Medicine (DIFM) DPG Resource – Members have full access to NMCD

• Nutrient-Drug Interactions

• Nutrient-Nutrient Interactions

• Nutrient Depletions

• Evidence and references

Natural Standard was founded by healthcare providers and researchers to provide high-quality, evidence-based information about complementary and alternative medicine including dietary supplements and integrative therapies. Grades reflect the level of available scientific data for or against the use of each therapy for a specific medical condition.

Nutritional Implications in Neurological/Mental Health

1. Headache/Migraine

2. Depression

3. Anxiety

4. ADHD

5. Autism Spectrum

(Rakel, 2012)

• Precipitating factors: menses, stress, weather, infection, fatigue, and sunlight, food triggers

1. Headache / Migraine

(Rakel, 2012)

Headache / Migraine

Nutritional Treatments Elimination of food triggers: wine, aged cheese, cashews,

chocolate, processed meats, caffeine (A,1) Biochemical Supplements Magnesium aspartate: 500 to 1000 mg nightly (B,2) Riboflavin: 200 mg twice daily (B,1) Coenzyme Q10: 150 mg daily (B,1)

(Rakel, 2012)

Headache / Migraine

Other Integrative Therapies Lifestyle

• Regular meals and sleep, aerobic exercise, headache calendar, stress management, avoid environmental triggers (A,1)

• Consider D/C hormonal birth control method if indicated

Mind-Body Therapy

• Biofeedback: 10 sessions (A,1)

• Cognitive behavioral therapy (A,1)

• Hypnosis (B,1)

• Mindfulness meditation: 8-week course (B,1)

(Rakel, 2012)

Nutritional Treatments Eliminate caffeine and simple sugars from diet; consume a Mediterranean-style or whole foods (low-processed) diet (B,1)

Biochemical Supplements

Vitamin B complex: with 400 mcg - 1 mg additional folic acid (B,2)

St. John’s wort: 900 mg daily (A,2)

SAMe: 200 mg 1-2x/day (titrate upward 1-2 wks) (B,2)

Fish oil: 1 g daily (titrate up to 6 g if not effective) (B,2)

2. Nutrition & Depression

(Rakel, 2012)

Depression

Other Integrative Therapies Lifestyle

• Recommend participation in aerobic and anaerobic exercises most days of the week (B,1)

• Encourage social interaction and positive relationships through enjoyable activities (B,1)

Phototherapy • 30-60 minutes of bright, white (full-spectrum) light daily from

approved light sources (B,1)

Psychotherapy • Supportive psychotherapy in addition to antidepressant

supplementation or pharmacotherapy is generally suggested (A,1)

(Rakel, 2012)

Nutritional Treatments Omega 3-fatty acid, B vitamin, and folic acid-rich foods; avoid caffeine and alcohol consumption (A,1)

Biochemical Supplements Vitamin B complex: with vitamin B6 (A,2) with added folic acid (B,2) (400 mcg) daily 5-Hydroxytryptophan (5-HTP): 150-300 mg daily (as serotonin-boosting alternative) (C,3)

3. Nutrition & Anxiety

(Rakel, 2012)

Anxiety

Other Integrative Therapies Botanicals • Kava: 50-70 mg three x/day; if lack of progress, consider valerian (or

combination) or pharmaceutical anxiolytic (B,2) • Concurrent psychotherapy recommended

Mind-Body Therapy • Psychotherapy: provides patient with skills to cope with anxiety (A,1) • Relaxation training: enables empowerment to control anxiety symptoms

Traditional Medical Systems (TMSs) • Generally utilized as adjunctive therapy unless specified by patient (C,1)

(Rakel, 2012)

Biochemical Supplements: Anxiety & Depression

1. N-Acetyl Cysteine (NAC)

2. Acetyl-L-Carnitine

3. S-adenosyl Methionine (SAM-e)

4. CoQ10

5. Alpha-Lipoic Acid

6. Creatine Monohydrate

7. Melatonin

Nierenberg AA Aust NZ J Psychiatry 2012 June 18

Nutritional Treatments

Assess diet and correct nutritional deficiencies (A,1)

Balanced blood glucose (regular meals with low glycemic index foods) (B,1)

Avoid dehydration (A,1)

May suggest avoiding coffee or tea as stimulants (B,2)

4. Nutrition & ADHD

(Rakel, 2012)

ADHD

Other Integrative Therapies Sleep & Activity • Consider melatonin, 0.3-3 mg one hour before bed; or

sedative herbal remedies (C,2) • Recommend at least 30 minutes vigorous activity daily (A,1) Stress and emotional self-management • Yoga, tai chi (C,1) Healthy environment; social support • Support networks, SMAR goals (B,1)

(Rakel, 2012)

• “Rather than thinking of autism as a brain disorder that has systemic effects, autism can be thought of as a systemic disorder that affects the brain.”

• Incidence of gastrointestinal problems in children with autism shown to be in range of 30% to 40%.

5. Nutrition & Autism Spectrum Disorder

(Rakel, 2012)

Nutrition & Autism Spectrum Disorder

Nutritional Treatments

Gluten-free, casein-free diet (B,1)

Biochemical Supplements

Omega-3s: 15 mg/pound total EPA, DHA (B,1)

Probiotics: 1 to 10 billion CFU daily (C,1)

Zinc: 20 to 25 mg daily, monitor mineral (copper) malabsorption (C,2)

(Rakel, 2012)

Autism Spectrum Disorder

Other Integrative Therapies Mind-Body Therapy • Intensive behavioral therapy (B,1) • Sensory integration therapy (C,1) • Auditory integration therapy (C,1)

Other Therapy • Speech therapy (C,1) • Occupational therapy (C,1)

(Rakel, 2012)

Screening for Nutritional Risk

• Various tools

• Depends on time/need of clinic

• Patient-completed vs. Practitioner- completed tools

• Key Elements

Nutrition Screening: Practitioner Assmt.

U.S. Nutrition Screening Initiative

Nutrition Screening: Self-Assessment

U.S. Nutrition Screening Initiative

Screening for Nutritional Risk

• Body Weight

– Body Mass Index (BMI): >27, <18.5

– Weight loss/gain: 10 lb (or more) in past 6 mo

• Eating Habits

– Limited availability access to food

– Eating alone

– Does not eat ≥ 1 day/month

– Poor appetite

U.S. Nutrition Screening Initiative Leyse-Wallace

Screening for Nutritional Risk

• Eating Habits (continued)

– On special diet

– Eats veggies ≤2 times daily

– Other questions based on food groups

– Difficulty chewing/swallowing

– >1 alcoholic drink/day ( ♀) >2 (♂)

– Smoking status

– Pain in mouth, teeth, gums

– Caffeine intake (ubiquitous) U.S. Nutrition Screening Initiative Leyse-Wallace

Screening for Nutritional Risk

• Living Environment – Lives on income of <$6000/year (per

individual in household)

– Lives alone

– Is housebound

– Lives in a home with inadequate heating/cooling

– Does not have a stove and/or refrigerator

– Is unable or prefers not to spend money on food (<$25-30/person spent on food/wk)

U.S. Nutrition Screening Initiative Leyse-Wallace

Screening for Nutritional Risk

• Functional Status – Bathing

– Dressing

– Grooming

– Toileting

– Eating

– Walking or moving about

– Traveling (outside the home)

– Preparing food

– Shopping for food or other necessities

U.S. Nutrition Screening Initiative Leyse-Wallace

Considerations for comorbidity

• Cancer: Weight loss, feeding difficulties, vitamin/mineral deficiencies/insufficiencies, blood sugar balance

• Cardiovascular Disease: Anti-oxidants in diet, Lipid levels, Balance of fats, Refined Carbohydrates

• Diabetes: Blood sugar balance, adequate protein, micronutrients (magnesium, chromium, others)

Referral to Dietitian

• “Reason for referral” (obesity, suspected food sensitivity, difficulty maintaining weight, disordered eating, Dx: IBD/ADHD/etc.)

• Send all clinic notes, pertinent medical records, laboratory reports, etc.

• Fax 913-588-0012 or email integrativemedicine@kumc.edu

• Patient Services Reps will send letter with nutrition assessment, recommendations, intervention plan

Let’s Revisit our Diet Diaries