Ruth Leyse-Wallace, PhD, RD

Linking Nutrition to Mental Health:
A Scientific Exploration

by
Ruth Leyse-Wallace PhD, RD

Citation: Leyse-Wallace, Ruth. Linking Nutrition to Mental Health: A Scientific Exploration. iUniverse, Inc. Lincoln NE, 2008.

Available at www.Amazon.com and www.iUniverse.com.

Comprehensive Nutritional Assessment Related to Mental Health

| Table of Contents

Patient ID______________________________________________________________M F

This is a suggested comprehensive assessment of nutritional status form. Noting these nutritional and psychological descriptors has potential use in patient care for creating a treatment plan and in research for discovering and quantifying the links between nutritional status and mental status. Some items may be omitted related to the population that is being assessed (for example many individuals will not need to be assessed for phenylalanine and related metabolites or enzymes).

It has been designed for ease in creating information and data that may be transformed to digital form (for example numerical and Yes/No answers that address a single issue).

Assessment of Nutritional Status (ANS) Related to Mental Health

(Circle any that apply; fill in any known values)

ANS Aspect 0. Risk factors Family History

Alcohol	Anemia	Anorexia nervosa	Bipolar disorder
Cancer	Depression	Diabetes	Food allergy
Intestinal disorder	Heart Disease	Hemochromatosis	Kidney disease
Migraine Headaches	Osteoporosis	Thyroid disorder	_______________
Gene analysis polymorphism (describe) ______________________________________________________

ANS Aspect 1. Physical Status / Body Composition (circle and/or fill in blanks)

Height: _______ Weight: _______ BMI: _______

Yes

BMI below 18.5

Yes

BMI above 30

Yes

Wt. Gain/Loss of ____ lbs in past ____ months. Loss of 10% of weight in 6 months

Yes

Muscle-Wasting

% body fat ______	Yes	No	Below 20% – Females / 10% – Males
	Yes	No	Above 35%

ANS Aspect 2. Dietary Habits

a. ____ Eats fewer than three times a day

b. ____ Makes food choices that do not meet the Food Guide Pyramid recommendations

Yes	No	6–11 servings starches	Yes	No	2–3 3-oz servings meat/substitute
Yes	No	3–5 servings vegetables	Yes	No	2–3 servings fruit
Yes	No	2–3 servings dairy foods	Yes	No	Eats mono-/polyunsaturated fats
Yes	No	Not over 10% calories from sugar
Yes	No	Not more than (F) l (M) 2 drinks alcohol/day
Yes	No	Low to moderate use of salt

c. ____Consumes more than 400 mg caffeine/day

d. ____Uses nutrient supplements:

Yes	No	Less than 100% DRI ____________________________________
Yes	No	About or equal to DRI __________________________________
Yes	No	More than 500% DRI or greater than UL __________________

ANS Aspect 3. Laboratory/ Biochemical / Metabolic (Above or Below Normal (N) range for

Laboratory/Biochemistry tests; Enter lab value and N value used for comparison)

Carbohydrate

___ Fasting Blood Glucose (FBS)___________	___ 2-hour postprandial glucose (2 hr PP) _____
___ Hemoglobin A1c (Hb_A1c) _____________	___ Galactose – enzymes and/or metabolites_____

Lipids

___ Total Cholesterol __________	____ High Density Lipoprotein __________
___ Low Density Lipoproteins __________	____ Triglycerides ___________________
___ EFA and/or metabolites (EPA, DHA, O-3, O-6) _______________________________________

Proteins and Amino Acids

___ Albumin ___________	___Pre-albumin _____ ____ BUN ______
___ Homocysteine _____	___Phenylalanine–related enzymes and/or metabolites ________
___ Other_________________________________________________________________________

Vitamins (Blood, Serum levels, or Vitamin-Dependent Enzyme)

___ B1 (Thiamin) (TKA) ___________	___ B2 (Riboflavin) ___________________________
___ B3 (Niacin) (Nicotinamide) ______	___ B6 (Pyridoxine) ___________________________
___ Biotin _______________________	___ B12 (Cobalamin) (MMA) ____________________
___ Folacin (Folic Acid) (FIGLU) ____	___ A (Retinol) _______________________________
___ C (Ascorbic Acid) _____________	___ D (Choleciferol) (Ergosterol) _________________
___ E (Tocopherol) ________________	___ K (Phylloquinones) _________________________

Minerals, Elements, Electrolytes, and Heavy Metals

___ Aluminum ____________________	___Calcium, DEXA scan ______________________
___ Chromium ____________________	___Copper _________________________________
___ Iodine, T-3, T-4 ________________	___ Iron, Hct, TIBC, Hemoglobin, MCV __________
___ Lead _________________________	___ Magnesium ______________________________
___ Mercury ______________________	___ Potassium _______________________________
___ Selenium _____________________	___ Sodium _________________________________
___ Other ________________________	____Other __________________________________

ANS Aspect 4. Clinical Signs and Symptoms (Presence of nutrient-based lesions determined by physical

examination (a–e) and/or other symptoms reported by client (f–g)

a. Oral Tongue Lips Gums Teeth ______________________________________________

b. Skin ___________________________________________________________________________

c. Nails ___________________________________________________________________________

d. Eyes ___________________________________________________________________________

e. Hair ____________________________________________________________________________

f. Yes No Diarrhea (more than two loose bowel movements/day)

g. Yes No Constipation (fewer than one bowel movement every three days)

h. Yes No Dental pain or discomfort that influences eating

ANS Aspect 5. Nutrient Drug Interaction (Potential for Nutrient/Drug or Drug/Nutrient interaction)
(Check those used, enter drug name if known)

___ Antacids __________________________	___ Antianxiety ________________________
___ Antibiotic _________________________	__ Antidepressant ______________________
___ Antidepressant (Tricyclic) ____________	___ Antidepressant (MonoAmine Oxidase Inhibitor)
	______________________________________
___ Antipsychotic ______________________	___ Antiseizure _________________________
___ Diet pills __________________________	___ Diuretics ___________________________
___ Hypoglycemic (oral) _________________	___ Insulin _____________________________
___ Laxative ___________________________	___ Lipid-lowering _______________________
___ Lithium ___________________________	___ Methotrexate ________________________
___ Tobacco ___________________________	___ Thyroid ____________________________
___Other ______________________________	___ Other ______________________________

Nonspecific Signs or Symptoms Reported by Client: (circle any reported; add any additional symptoms)

Appetite Concentration reduced Energy level reduced / increased

Fatigue Headaches Irritability

Memory Problems Sleep Problems Tearful

_______________ ________________ _______________

Additional Nutritional Observations, Comments:

Summarize findings of ANS by listing the risks in each stage contributing to determination of an individual’s Stage of Nutritional Injury.

ANS 0: 0–0.9 = Risk of nutritional injury ____________________________________

ANS 1 _______________________________________________________________

ANS 2 _______________________________________________________________

ANS 3 _______________________________________________________________

ANS 4 _______________________________________________________________

ANS 5 _______________________________________________________________

Non-specific signs and symptoms___________________________________________

Assessment of Nutritional Status: Stages of Nutritional Injury

The Stage of Nutritional Injury (a descriptor of nutritional status) may be assigned to each individual based on any or all of the findings from the assessment and the professional judgment of the practitioner.

Use the descriptions below to determine the Stage of Nutritional Injury of the individual assessed. The highest level present is most often the designated Stage of Nutritional Injury.

Stages of Nutritional Injury

I. Depletion of nutrient stores, adaptation (Potential indicated by ANS Aspects 1 and 4 )

II. Reserves exhausted (Potential: Stage I indicators of depletion or excesses lasting for six weeks or longer)

III. Physiologic and metabolic alterations (Indicated by ANS Aspect 2 )

IV. Nonspecific signs and/or symptoms (Potential indicated by reports of fatigue, headaches, loss of appetite, decrease in attention, insomnia, etc.)

V. Illness or specific signs and/or symptoms (Indicated by ANS Aspects 3 and 5)

VI. Damage irreversible or nonresponsive to treatment (Potentially including but not limited to loss of absorption sites resulting from bariatric surgery, bone loss, vision loss, loss of nerve function)

Stage of Nutritional Injury: _________ (0–VI)

GAF score ________ (date _______) GAF score ________ (date_______)*

DSM-IV Diagnosis Axis I _____________ Axis II ______________________

*GAF: Global Assessment of Functioning is Axis V of a multiaxial diagnosis by a psychiatrist.

Printed name, signature and credentials of person completing the Nutritional Assessment form

_________________________________________________________________date_______________

For permission to use material from this site or copyrighted literature,
please contact Ruth Leyse-Wallace PhD, RD at RthLys@cox.net.
Copyright © 2010 Ruth Leyse-Wallace. All rights reserved.
Design by John Atkinson

Ruth Leyse-Wallace, PhD, RD

Linking Nutrition to Mental Health:A Scientific Exploration

Comprehensive Nutritional Assessment Related to Mental Health

Linking Nutrition to Mental Health:
A Scientific Exploration