Nutrition and Mental Health. Leigh Wagner MS, RD KU Integrative Medicine

Transcription

1 Nutrition and Mental Health Leigh Wagner MS, RD KU Integrative Medicine

2 KU Integrative Medicine

3 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.

4 Nutrition Program at KU IM Nutrition Counseling Individualized nutrition assessment Nutrition physical exam Body composition analysis Laboratory testing Food sensitivities Cancer, Digestive Issues, Autoimmune diseases, Metabolic problems Healing Foods Kitchen Cooking classes for beginners and some intermediate-level home chefs. KU Med Center Campus Integrative Medicine Afternoons $15-25 depending on menu

5 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..

6 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.

7 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

8 What is Good Nutrition?

9 Food Processing

10 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!

11 KU Healing Foods Kitchen

12 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

13 The Dietitian s world Biochemistry Vit E, Quercitin, EPA Membrane Phospholipids Phospholipase A2 Arachidonic Acid Vitamin E, Quercitin Licorice, Turmeric Corticosteroids EPA & DHA Turmeric, Onion, Garlic, Boswellia Sulfasalazine 5-Lipoxygenase (LOX) 12-Lipoxygenase (LOX) Series 4 Leukotrienes Cycooxygenase 1 (COX) Cyclooxygenase 2 (COX) Prostaglandins Series 2 Ginger, turmeric, Black Williow, Wintergreen NSAIDS Thromboxanes A 2, B 2

14 Formation of Neurotransmitters Dopamine β-hydroxylase Vitamin C, COPPER, O 2

15 Formation of Neurotransmitters L-Amino Acid Decarboxylase PLP (Vitamin B6)

16 Nutrition on a Spectrum Candy Bar Chocolate- Covered Granola Bar Where are you now? Granola Bar Fruit + Handful Nuts Whole Food Bar

17 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

18 Nutrition in Integrative Medicine Food and Nutrition Environment Mind Lifestyle Genetics Body Spirit Your Health

19 Your Top 3 Priorities List the most important things in your life

20 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?

21 Past National Nutritional Guidelines

22 New National Nutritional Guidelines

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24 You are what you EAT? IDU: Nutrition Assessment Tool Ingestion: Food, Beverages, Supplements Digestion: Assess GI Tract from Mouth to Anus Utilization: GI; Lab Evidence; Nutrition Physical You are what you CAN ABSORB!

25 Structure = Function Composition of Brain Water 77-78% Lipid 10-12% Protein 8% Carbohydrate 1% Soluble Organic Substances Whole Brain (%) 2% Inorganic Salts 1% Reference: McIlwain H, Bachelard HS. Biochemistry and the Central Nervous System, Edinburgh: Churchill Livingston, 1985 Table adapted from:

26 Mental Health & Nutrition Dynamic models describe mental processes and phenomena that change over time, more like a movie than a photograph, with multiple variables interacting over time. Bystritsky et al, 2012

27 Non-linear dynamical psychiatry Bystritsky et al, 2012

28 Nutrition is also non-linear

29 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.

30 Resources

31 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

32 Healthy or Possible Risk of Nutritional Injury (Genetics:Genotype Host: Phenotype Environment: Agents) Stages of Nutritional Injury Conceptual Model adapted with permission from work of Guillermo Arroyave Stage 0 Examples of conditions: Family history of diabetes, alcoholism, celiac disease, bipolar disease Examples of nutrients: Regular alcohol intake, Stage I Diminishing Reserves/ Building Excess Stages of Nutritional Injury Stage 1 and 2 Omits food groups due to allergies and/or preferences Eats 1 meal/day Use mega-dose supplements Fad diet use Pro. Carb Vit A,D, Fol, E, C Iron, CA Stage II Reserves Exhausted Stage III Physiologic and Metabolic Alterations Stage 3 Wt gain/loss in past 3-6 months High Chol, Glu, Hcy Relevant score on ED assessment Low Fol, Vit B 12, C Iron, Ess. Fatty Acids Hi Trig,Chol, Hcy Stage IV Nonspecific Signs and Symptoms Stage 4 Fatigue Headaches Irritability Trouble concentrating Oral lesions Nausea Diarrhea Poor appetite B-Vit deficiency Low carb intake Insufficient or excess Stage V Illness Stage 5 Metabolic Syndrome Bulimia Gestational diabetes Alcohol dependence Medication with Nutrient-Drug interaction Low Vit, Min intake MAOI Medication Lactose intolerance Stage VI Permanent Damage Stage 6 Bariatric surgery Dementia Phenylketonuria Xerosis with ulceration Vit-A blindness Pernicious anemia Vit B 12, A Phenylalanine Calorie intake 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: Leyse-Wallace

33 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

34 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

35 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) Ruth Leyse-Wallace PhD, RD

36 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): Ruth Leyse Wallace PhD, RD

37 Walsh s Repeat Offenders Copper overload B6 Deficiency Zinc Deficiency Methyl/folate imbalances Oxidative stress overload Amino acid imbalances Walsh, 2012

38 Copper Overload Biochemical Manifestations Lower dopamine and increase norepinephrine in brain Dopamine β-hydroxylase Vitamin C, COPPER, O 2 Walsh, 2012

39 Copper Overload Clinical Manifestations (associated with) Paranoid schizophrenia Bipolar disorder Postpartum depression ADHD Autism Violent behavior Walsh, 2012

40 Vitamin B6 Deficiency Biochemical Manifestations Poor formation of dopamine, GABA, serotonin Participates in over 80 biochemical reactions in the body L-Amino Acid Decarboxylase PLP (Vitamin B6) Walsh, 2012

41 Vitamin B6 Deficiency Clinical Manifestations Irritability Depression Short-Term memory Psychosis Overdose: Neuropathy (reversible), vivid dreams Combs, 2008 (Walsh, 2012)

42 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

43 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

44 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

45 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

46 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

47 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

48 Oxidative stress overload Biochemical Manifestations Elevated urine pyrroles Low plasma zinc and PLP Depressed serum glutathione Elevated non-ceruloplasmin serum copper Walsh, 2012

49 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

50 Amino Acid Imbalances Biochemical Manifestations Altered synthesis of Serotonin (tryptophan) Dopamine and norepinephrine (Phe, Tyr) GABA (Gln) Histamine (Histidine) SAMe (Met) Walsh, 2012

51 Amino Acid Imbalances Clinical Manifestations Anxiety Depression Psychosis ADHD Walsh, 2012 Gaby, 2011

52 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)

53 NUTRITION AND DIAGNOSIS- RELATED CARE

54 Evidence versus Harm Grading Icons Integrative Medicine by Dr. David Rakel (U. Wisconsin Family Medicine)

55 Evidence versus Harm Grading Icons Most efficacious and safest Least efficacious and highest risk for harm

56 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

57 Natural Standard was founded by healthcare providers and researchers to provide highquality, 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.

58 Nutritional Implications in Neurological/Mental Health 1. Headache/Migraine 2. Depression 3. Anxiety 4. ADHD 5. Autism Spectrum (Rakel, 2012)

59 1. Headache / Migraine Precipitating factors: menses, stress, weather, infection, fatigue, and sunlight, food triggers (Rakel, 2012)

60 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)

61 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)

62 2. Nutrition & Depression 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) (Rakel, 2012)

63 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 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)

64 3. Nutrition & Anxiety 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): mg daily (as serotonin-boosting alternative) (C,3) (Rakel, 2012)

65 Anxiety Other Integrative Therapies Botanicals Kava: 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)

66 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

67 4. Nutrition & ADHD Nutritional Treatments (Rakel, 2012) 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)

68 ADHD Other Integrative Therapies Sleep & Activity Consider melatonin, 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)

69 5. Nutrition & Autism Spectrum Disorder 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%. (Rakel, 2012)

70 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)

71 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)

72 Screening for Nutritional Risk Various tools Depends on time/need of clinic Patient-completed vs. Practitioner- completed tools Key Elements

73 Nutrition Screening: Practitioner Assmt. U.S. Nutrition Screening Initiative

74 Nutrition Screening: Self-Assessment U.S. Nutrition Screening Initiative

75 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

76 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

77 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

78 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

79 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)

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

81 Let s Revisit our Diet Diaries

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