From the ADA Nutrition Care Manual: Nutrition Intervention for Dietitians working with patients who have

mood disorders: Nutrition Intervention is the third step in the Nutrition Care Process. See the Nutrition Interventions in the Resource section for more information on Goal Setting, Developing a Nutrition Prescription, and further information on planning, setting, and using the Nutrition Intervention. Planning the appropriate nutrition intervention is the third step of the Nutrition Care Plan. Nutrition interventions are based on the Nutrition Diagnosis. Nutritional therapy often includes the following: Meal structuring/timing/composition for mood stability and controlling hunger Nutrient-dense foods for nutritional adequacy while minimizing the risk of weight gain Planning for fiber and fluid adequate for bowel regularity while taking psychotropic drugs Planning for appropriate low-energy fluid choices to counteract dry mouth and prevent excess intake of energy and caffeine Nutrition interventions should address, as appropriate: Nutrient-drug interactions: constipation, inadequate or excessive fluid intake or the need for a tyramine-restriction. It is advisable to refrain from blaming the medication for side effects while working to minimize the consequences. Weight changes should be addressed with goals for energy intake and exercise accompanied by an individualized eating guideline and sample meal plan. Inclusion of appropriate snacks will help address alterations in appetite. Regular follow-up is recommended. Referral to a nutrition education and exercise group, when available, is helpful. Access to adequate and acceptable meals in the hospital, at home, or in a residential facility or other living situation. Education and instructions should accommodate an individuals emotional and mental status, educational level, interest, and other personal factors such as religious beliefs, cultural habits, and food preferences. Commonly used nutrition interventions include the following: ND - Food or Nutrient Delivery 1. Meal and snacks: Regular eating event (meal); food served between regular meals (snack) ND 1.1 General/healthful diet ND 1.2 Modify distribution, type, or amount of food and nutrients within meals or at specified time ND 1.3 Specific foods/beverages or food groups 3.2 Vitamin Mineral supplements ND 3.2.1 Multivitamin/mineral Copyright 2011 American Dietetic Association. All Rights Reserved. Web2

ND 3.2.2 Multitrace elements ND 3.2.3 Vitamin: specify ND 3.2.4 Mineral: specify E - Nutrition Education 1. Initial/brief nutrition education: Build or reinforce basic or essential nutrition-related knowledge. E 1.1 Purpose of the nutrition education 2. Comprehensive nutrition education instruction or training leading to in-depth, nutritionrelated knowledge or skills. E 2.1 Purpose of the nutrition education E 2.2 Recommended modifications C - Nutrition Counseling 1. Theoretical basis/approach: The theories or models used to design and implement an intervention C 1.2 Cognitive-Behavioral Theory C 1.3 Health Belief Model C1.4 Social Learning Theory C1.5 Transtheoretical Model/ Stages of Change 2. Strategies: Selectively applied evidence-based methods or plans of action designed to achieve a particular goal C 2.1 Motivational interviewing C 2.2 Goal setting C 2.3 Self-monitoring C 2.4 Problem solving C 2.5 Social support C 2.6 Stress management C 2.7 Stimulus control C 2.8 Cognitive restructuring C 2.9 Relapse prevention C2.10 Rewards/contingency management RC - Coordination of Nutrition Care 1. Coordination of other care during nutrition care: Facilitating services with other professionals, institutions, or agencies during nutrition care

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RC 1.1 Team meeting RC 1.2 Referral to registered dietitian with different expertise RC 1.3 Collaboration/referral to other providers RC 1.4 Referral to community agencies/programs Note: Terminology in the examples above is from the American Dietetic Association's International Dietetics and Nutrition Terminology, 3rd edition. Code numbers are inserted to assist in finding more information about the diagnoses, their etiologies and signs and symptoms. Dietitians should not include these numbers in routine clinical documentation. American Dietetic Association. Nutrition Care Manual. Mood Disorders : Nutrition Intervention. http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=77580. Accessed December 1, 2010.

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From the ADA Nutrition Care Manual: Nutrition Prescription for Dietitians working with patients who have mood disorders: The nutrition prescription may address any or all of the factors below: Tyramine: o A diet providing minimal tyramine is recommended if a monoamine oxidase inhibitor medication is prescribed at doses of 9 mg/day or 12 mg/day. o Intake of 6 mg tyramine/day is considered a dangerously high level. Oral instruction regarding the rationale for the diet plus written educational material needs to be provided to the patient. The registered dietitian should answer any questions of the patients and family. (See Client Education for handout for a low tyramine diet) Omega-3 fatty acids: 6 oz to 8 oz fish/week or 750 mg to 1000 mg essential fatty acids/day Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA): o A healthy dietary allowance for n-3 long chain fatty acids (LCFA) for current US diets was estimated at 3.5 g/d for a 2,000 kcal diet. This allowance for n-3 LCFAs can likely be reduced to one-tenth of that amount by consuming fewer n-6 fats. o Oily fish are the major dietary source of EPA and DHA. o Three n-3 polyunsaturated fatty acid (PUFA)-enriched eggs provide approximately the same amount of n-3 PUFAs as one meal of fish. o Krill is similar to fish oil, except it contains naturally occurring phospholipids and more EPA that standard fish oil: 240 mg/g EPA in krill vs 180 mg/g in standard fish oil. o EPA and DHA provided by selected fish are listed in the table below: Some Food Sources of EPA (20:5n-3) and DHA (22:6n-3) (Higdon 2005) Amount (oz) providing Food Serving EPA (g) DHA (g) 1 g EPA + DHA Herring, Pacific 3 oz 1.06 0.75 1.5 Salmon, Chinook 3 oz 0.86 0.62 2 Sardines, Pacific 3 oz 0.45 0.74 2.5 Salmon, Atlantic 3 oz 0.28 0.95 2.5 Oysters, Pacific 3 oz 0.75 0.43 2.5 Salmon, sockeye 3 oz 0.45 0.60 3 Trout, rainbow 3 oz 0.40 0.44 3.5 Tuna, canned, white 3 oz 0.20 0.54 4 Crab, Dungeness 3 oz 0.24 0.10 9 Tuna, canned, light 3 oz 0.04 0.19 12 Sodium: A consistent, moderate, intake of sodium is required for maintaining a stable, effective level of blood lithium from a given dose of medication. Fiber: Dietary Reference Intakes (DRI) (Adequate Intakes [AI]): 14 g / 1,000 kcal daily Fluid: o Total water AI: men: 3.7 L/day (125 oz); 80% = 100 oz in beverages o Total water AI: women: 2.7 L/day (91 oz); 80% = 73 oz in beverages

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o 80% of total water is generally from water and beverages; 20% from food sources. Vitamin E: A low-fat diet may result in less than the DRI of 15 mg/day; supplement may be required to meet DRI Concentrated sweets/sugars as % of total energy intake o Criteria of World Health Organization: 10% o Criteria of Institute of Medicine: 25% Caffeine: A moderate caffeine intake is considered to be 350 mg/day to 450 mg/day.

Example: 1 cup coffee @ 100 mg + 1 cup tea @ 80 mg +12 oz cola beverage @ 25 mg +1 Excedrin tablet @ 60 mg +1 oz. semi-sweet chocolate @ 13 mg Total caffeine = 278 mg Grapefruit juice: Omit from the diet, as it interacts with many psychotropic drugs; intake can inhibit normal breakdown of drug and increase active blood levels (Logan 2004). Information regarding Ordering Nutrition Prescriptions is available in the Resource section. American Dietetic Association. Nutrition Care Manual. Mood Disorders : Nutrition Prescription. http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=77581. Accessed December 1, 2010. Copyright 2011 American Dietetic Association. All Rights Reserved. Web2

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