CHAPTER 3

Listening to Your Clients About Their
Diet and Health: Assessment Techniques

Diet Essential: Symptoms tell a story of nutritional
and emotional challenges.

We begin an integrative mental health nutrition assessment during the first meeting with a client. As mental health practitioners, we usually conduct psychologically oriented intakes and assessments; however, one of the most illuminating additions to mental health assessment is the inclusion of a comprehensive physical health and nutrition/dietary history.

Over time, as we learn to put together the pieces of someone’s story, and the meaning it has for her health and well-being, so do we learn to see the patterns of their physical health history and the bidirectional effects of physical and mental influences on health.

The inclusion of a physical health history along with a nutritional history and current food and preparation patterns will help identify and prioritize the next steps, including underlying causes that can be corrected through dietary and nutritional interventions.

ASSESSMENT AS EDUCATION

The partnership model suggests that clinician and client work together as partners in finding the best approaches for the client. The clinician works to empower the client and walk with her step by step when necessary. It is not authoritarian; it is authoritative. The clinician supports the client to discover what works best for him or her in the context of best available knowledge. Most people are conditioned to being told what to do by health practitioners; the clinician finds opportunities to empower the client as her or his own agent of change.

When conducting a client assessment, I share with the client the metaphor of a jigsaw puzzle that we are co-constructing. Most of my clients have tried many approaches to restoring their health, often with limited success. This is in part because each clinician puts together a few pieces of the puzzle, but the client never has the opportunity to see how all the pieces fit together. In my experience this is the major challenge facing clients when they seek help. They see specialists for each type of symptom, whether mental or physical, but no one helps them to “put the pieces together” in order to tell a coherent story. I share with the client that we will identify and put together seemingly disparate pieces about one’s whole health history and symptoms in order to understand how everything fits together, and from this we will create a new picture that provides insight into causative factors. These then will point us in the direction of the next steps to take.

People want to know why they feel the way they do, and they will more readily engage in making changes if they understand how these changes will help them. Symptoms tell a story of nutritional and emotional challenges. Our role is to listen to the story and, together with the client, make the story coherent and actionable.

The assessment process begins to . . .

1. Educate the client about the nutritional basis for her or his symptoms.

2. Connect mental health symptoms with physical symptoms or condition.

3. Bridge health experiences and symptoms of the past with those in the present.

4. Identify where food-related behaviors may be an effort to reestablish balance in the system.

5. Identify some alternatives to current behaviors that will bring positive, lasting results.

6. Provide hope for methods that can reduce any current side effects .

7. Identify three nutritional goals to begin the change process.

Avoid Shame During Assessment

Any illness or symptom can result in a sense of shame. This is especially so with alcohol/chemical dependency, obsessive-compulsive disorder (OCD) behaviors, body dysmorphic disorder (recall that this involves a person believing one’s body is somehow defective), eating disorders including purging, and obesity. The client may not readily explore these elements of her or his history unless prompted. If I sense that a client would benefit from exploring these areas and she or he does not seem comfortable raising the topics or responding during the intake, I identify them as topics we can explore down the road. I may say: “I can appreciate that right now it may be difficult to talk about this. How about if we focus on (name a less triggering topic) right now and we can revisit this down the road?”

Because there is a high correlation between the experience of trauma in early life and substance use and eating disorders, I always educate the client about the role of affective dysregulation and the disruption of biochemistry by chronic stress—and the tools that exist to nourish the brain, mind, and body toward balance.

In response to a client who has bulimia and is a survivor, I might say, “We know from clinical experience that most people who experience bulimia have histories of sexual abuse. While we don’t understand all of the interrelationships, we do understand that it is by and large an effort to reestablish balance. Let’s explore what your behaviors are telling us about what your body-mind needs in order to establish balance and a sense of well-being, and then we can explore what options are out there that may more effectively support your health.”

When discussing management and self-care behaviors, it is important to avoid language or attitudes that may inadvertently add to the feelings of shame. This requires a matter-of-fact approach; there are many explanatory systems about mental health illness rooted in cultural, religious, and popular belief systems.

Shame is closely related to self-criticism and blame arising from affect dysregulation. Building in compassion-based skills to address these issues early and as they arise will improve self-care and adherence behaviors and ultimately overall outcomes. Compassion therapy (Gilbert, 2009) applies a mindfulness approach and reinforces and stimulates feelings of safeness, warmth, and connectedness that lead to self-soothing. Because food and drugs and medications are often central to these efforts, understanding the role they play will be essential to avoid engaging in shaming dialogue. Women with eating disorders who reduced shame and increased self-compassion have better treatment outcomes for eating disorders (Kelly, Carter, & Borairi, 2014). This suggests that when someone “falls off the wagon” with a particular protocol or regimen, she or he is supported in a nonjudgmental way to identify what they need to return to their program. This will include reframing shame-based statements .

SAMPLE DIALOGUE 1: REFRAMING SHAME-BASED STATEMENTS

Client 1: I just have no willpower when it comes to donuts. If I see them at work on the break table, I just gobble them up. I have always been bad that way.

Therapist: Donuts are designed with so much sugar and flour that they act like drugs. No wonder you and many people find it hard to turn down donuts. It is not about willpower. Let’s strategize some nutritional support that will help you.

Client 2: I went to my friend’s birthday party and she offered me a platter, and I ate two pastries, and now I have ruined everything I was working toward.

Therapist: You have not ruined everything you are working toward. You have had a brief setback, but there’s nothing keeping you from your goals. It’s hard to say no at a birthday party. Did you feel you would “standout” or offend your host if you said “no thank you”?

Client 3: I have been depressed all my life and on meds since I was 11. I just think this is the way I am. There’s just something wrong with me and that’s how it is going to be.

Therapist: I can appreciate you feel despair at times. You have worked with great courage to restore your health and I am confident of your success. I am thinking about the time you shared with me that you grew up very poor, and often went hungry, and that when you did eat, it was mainly cereal. In many ways this set the stage for your body to crave alcohol and likely led to your body and brain not getting what you needed. You have come a long way in recovery. I know that we can work together to identify the foods and support you need to feel better, and we will work together to identify that and I will support you in achieving that (see Appendix B for the Client Intake Form).

INITIAL INTAKE FORM AND ANALYSIS

The following sections map the assessment (provided in handout printable format in the Appendix). In what follows, I provide an explanation of the meaning of the questions in the context of mental health nutrition and how answers may be understood and interpreted.

There are a number of sections to the assessment, and you may find that you will conduct it in several stages. The client can fill out the assessment and then review it in the office as a basis for discussion and amplification of answers. Like many assessments, it need not be reviewed in order but tailored to the presenting need and tolerance of your client. There will be some parts to the assessment that may feel overwhelming at times to your client, in which case you can proceed slowly, as needed. It is also possible that a client will leave parts blank, in which case you can review the content verbally.

Food-Mood Diary and Clinician Checklist

The Food-Mood diary provides a 3-day window into food habits and patterns and how the client links mood and energy to food quality, quantity, and timing of intake. It provides the clinician with a quick visual of client nutrition and helps to identify initial places to start the change process. I provide this handout after the first appointment so that I can explain it to my client. The client can take it home, and we can review it together at the second appointment. Then, together with a review of the complete intake and a review of this diary, we can begin to identify goals for change. The Food-Mood diary may also serve to initiate some quick changes that will bring about significant improvement in mood and energy and thus engage hope and positive attitude. Hence, one need not wait until the complete intake is finished to engage the change process.

As you sit with the client to review the Food-Mood diary, use the Clinician Checklist as a step-by-step approach to review each section of the Food-Mood diary. Use the interpretation and suggestions as initial steps/goals for the client toward well-being. When analyzing the Food-Mood diary, ask the client to follow along with a copy of the diary, which you will also have in hand. She or he can amplify anything. Some clients feel impatient filling out diaries and make notes only. In this case you can use these notes as prompts to clarify or deepen the answers provided.

In Boxes 3.1 and 3.2, I have provided examples of a Food-Mood diary and Clinician Checklist followed by a dialogue with review and analysis.

Box 3.1

Sample Food-Mood Diary

Food/Mood Diary
Name:     (Joan Client)                  Date: (dd/mm/yy)

Write down everything you eat and drink for three days, including all snacks, beverages, and water. Please include approximate amounts. Describe energy, mood, or digestive responses associated with a meal/snack and record it in the right-hand columns. Use an up arrow (↑) for an increase in energy/mood, down arrow (↓) for a decrease in energy/mood, and an equal sign (=) if energy/mood is unchanged.

Time of waking:     6:30                a.m./p.m.

Meal	Beverages	Energy Level (↑, ↓, or =)	Mood (↑, ↓, or =)	Digestive Response (gas, bloating, gurgling, elimination, etc.)
Breakfast (Time: 7:00 a.m.) No breakfast	Coffee, creamer, 2 Equal	Good	Energy low around 9:30 a.m., starting to feel stress of the day	Pain in stomach
Snacks (Time: 9:30 a.m.) Danish pastry	Coffee, creamer, 2 Equal	Was low but then got better	Stressed about work deadlines
Lunch (Time: 1:00 p.m.) Salad bar, French dressing, wheat roll with butter, fruit cocktail	Diet coke Glass of water	Better during lunch, dreading afternoon	Good lunch with coworker	Gurgling and a little discomfort about an hour after lunch
Snacks (Time: 3:20 p.m.) 1 Reese’s peanut butter cup	Coffee, creamer, Equal	Flagging, headache
Dinner (Time: 7 p.m.) Lean Cuisine Pizza, Applesauce	Iced tea	Exhausted	Tired and irritable
Snacks (Time: 8:30 p.m.) Reese’s peanut butter cup

Box 3.2

Clinician Checklist for the Food Diary

Joan’s Checklist #1
Question	Fill in Answer/ Notes	Goals and Recommendations
1. How much time passed between when the client awakens and when the client eats breakfast? Is the client eating breakfast?	3 hr /not eating breakfast	One should always eat breakfast, containing at least 3–4 ounces of protein within 30 minutes of waking for proper energy and blood sugar balancing.
2. How much water/broth is the client drinking throughout the day?	3 coffees 2 diet cokes 1 ice tea 8 oz. water Joan =180 lb/50% Needs at least 60–90 oz/day	Water intake should be about 50% of body weight every day in ounces (example: if a person weighs 160 lb, she or he should be drinking 80 ounces of water daily).
3. How often is the client eating? How many hours between each meal or snack?	Is snacking but with sugary products not food per se; 6 hr between lunch and dinner	Food should be eaten every 3–4 hours to prevent mood swings, and the client should have at least 3 meals/day and 2 snacks.
4. How many servings of vegetables is the client eating per day?	1 salad	At least 3 servings of vegetables should be eaten every day. A serving equals from ½ to 1 cup.
5. Is the client eating raw vegetables and fruits?	1 salad/maybe 1 apple/applesauce	At least 1–3 servings of raw fruit or vegetables should be eaten every day.
6. Is the client eating enough protein? Note if lack of protein corresponds to drops in mood.	Very limited protein	Proteins help to stabilize energy and balance mood and should be emphasized during the daytime hours.
7. Is the client eating enough fats? Note if lack of fats corresponds to mood shifts.	Poor-quality fats	Fats help to stabilize energy and balance mood and should be emphasized during the daytime hours.
8. How many servings of starchy carbohydrates is the client eating and at what times of day?	Throughout day/pastries, candy, roll/pizza	During the day carbohydrates are best when combined with protein, and carbohydrates should be emphasized in the evening for relaxation.
9. What is the quality of the food the client is eating (freshly prepared vs. canned or prepackaged foods)?	Poor-quality food	Recommend whole, fresh, organic foods over packaged and canned foods.
10. Is the client eating enough soluble fiber?	Some fiber: apples	Soluble fiber is found in foods like oat bran, nuts, beans, lentils, psyllium husk, peas, chia seeds, barley, and some fruits and vegetables. Men should be eating about 38 grams/day and women 25 grams/day.
11. Is the client eating enough insoluble fiber?	Some in grain sources	Insoluble fiber is found in wheat bran, corn, whole grains, oat bran, seeds and nuts, brown rice, flaxseed, and the skins of many fruits and vegetables.

During the review of the Food-Mood diary, you have the opportunity to identify basic dietary patterns and to ask additional questions. This initial review also allows an assessment of client willingness to make certain changes within the context of the overall stages of change (see Chapter 9 ). With the completion of the Food-Mood diary, there is enough information to begin goal setting (see Appendix C for printable versions of the Food-Mood Diary and Clinician Checklist) .

SAMPLE DIALOGUE 2: FOOD-MOOD DIARY

Clinician: Hi Joan, thank you for filling out this Food-Mood diary. I’d like to review it with you, and we may be able to discover some ways to improve your sense of well-being. One of the first things I notice is that you don’t actually eat breakfast. Is that because you’re not hungry when you wake up?

Joan: Yeah, I just don’t have any appetite.

Clinician: I see that you drink coffee, and I notice that you have some pain in your stomach in the morning. Can you tell me about that?

Joan: I wake up with it every morning, I don’t know if it is just stress, but it is kind of pain and nausea.

Clinician: Does it get better or worse when you drink coffee?

Joan: It stays the same . . . maybe a little worse but I need the energy so I just put up with it and if it gets real bad I take an aspirin.

Clinician: Joan, I think that is a priority we can work on and help you feel better. Around 9:30 you had a pastry with another coffee. One of the things you said here is that your energy is a little low by 9:30. That is very common when we don’t eat breakfast. Our energy drops and then we grab something to boost it. One of the things we’ll talk about are the ways you can increase your energy by changing some of the foods that you’re eating and the times you eat. How does that sound to you?

Joan: That sounds good.

Clinician: It looks like at lunchtime you had a salad. Is this something you do every day or was this unusual?

Joan: Yes, though sometimes I have a lunchmeat sandwich. And sometimes instead of a fruit cocktail, I might just have an apple, but I really like the sweet in the fruit cocktail. I feel like it gives me a little energy. I had been drinking regular coke but then decided to switch to diet coke, because I thought that was better for me.

Clinician: I can understand that. In general, sugary foods only give a short-term energy boost and from what I see in your mood and energy sections later in the day your energy drops again. Again, with a few simple changes I think you will have more sustained energy throughout the day. One of the things I notice is that you had a little bit of discomfort after lunch.

Joan: Yeah, I always end up having cramping, low down in my stomach.

Clinician: Do you mean your stomach, or lower down in your belly where your intestines are? (Note: Point to the different locations of the abdomen as people often call their intestines their stomach.)

Joan: Oh, I guess it is lower down than the stomach .

Clinician: Can you place your hands on your belly where you feel the pain?

[Joan places her hands on her descending colon.]

Clinician: Ok. We will talk about that in a bit.

Clinician: Could I clarify, this next area under mood is not filled in, but I noticed that by the middle of the afternoon your energy drops. What happens to your mood at that time?

Joan: I start to get depressed and bark at my office manager.

Clinician: Do you feel better after the coffee and the Reese’s peanut butter cup?

Joan: Well, I think so, maybe for an hour, but then I feel a little nauseated and I still find it hard to get through the rest of the workday. I start to feel antsy.

Clinician: I notice that you eat dinner at about 7 p.m.—a Lean Cuisine pizza and applesauce—is this a normal type of dinner for you and regular time?

Joan: Yes, I try to get something healthy that I can just throw in the microwave. I think the applesauce is good for my constipation, though then sometimes I get too loose.

Clinician: I notice that by this time you’re really feeling exhausted and tired and irritable. How are you feeling in your belly?

Joan: Well, one of the things I notice before I go to bed is that I have kind of a hot pain coming up into my throat, especially when I lie down. Sometimes it is so bad I take some Tums.

Clinician: Joan, I notice that in the middle of the evening you have another peanut butter cup. Is that because you’re hungry or you want something sweet?

Joan: Well, I feel like it settles my stomach. I’ll be watching TV and . . . I don’t know . . . it just tastes good. I feel a little lonely since my divorce. I know I shouldn’t, but . . .

Clinician: I can imagine you feel very lonely since your divorce and feeling crummy every day like you have described here doesn’t help either. I feel confident that we can help you feel better physically, and this in turn will help you get back on your feet again. I have no doubt of it, Joan. Is there anything else you want to tell me about your food diary before I share? You can make some nutritional changes that will help the depression, fatigue, and stress and pain we have been discussing.

Joan: Well, the only thing is that I do like to cook, but I just don’t seem to have the time or energy after a day of work. I know some of this probably isn’t that great for me. I just feel so overwhelmed and stressed most of the time I just can’t take on anymore.

Clinician: Yes, I can appreciate that. I am glad you like to cook. It is really important for you to do so and you also lead a busy professional life. I will have some suggestions for you so that you can do some more cooking. It will make a big difference in your energy and health, and I don’t think it will take up too much of your time.

Dialogue Analysis and Recommendations

Clinician: I’d like to review some areas in this diet where we can find some initial improvement and they won’t be too difficult to implement. And I think I have some answers as to why you feel the way you do. If you undertake some initial changes, you will experience very good improvement in your energy and depression pretty quickly. I know that we are working on your feelings about the divorce and John leaving you and your sadness. We have talked about how those feelings won’t go away quickly, but let’s focus on some areas you can control now and ‘tease out” how your diet is affecting your mood and energy. Once we clear that up, then we will know a bit more about the best ways to focus on your sadness and depression. Shall we go through this together?

Joan: Yes.

Clinician: The first thing I notice is that when you wake up, you have some pain, but you also aren’t very hungry and you drink coffee, but not until 9:30 do you put anything in your stomach. I’d like to work with you to eat something, even if it is small and simple, soon after you wake up. Is that doable for you?

Joan: Yes, I can try.

Clinician: Once you try it for a few weeks, I know you will get the results you want. Let’s also focus on reducing the pain in your stomach; when you drink coffee on an empty stomach, it can create excess acid; I suspect you may have some acid problems because what you describe at night when you feel that hot pain is also a sign of that. Things like a lot of coffee and starches can cause the symptoms you describe. And, even though you take aspirin for the pain, the aspirin just makes it worse. So it is important never to drink coffee on an empty stomach. You might look into the low-acid coffees on the market, and once we get your energy boosted a bit, how would you feel about just having some coffee in the morning and passing on the afternoon cup? Would you think about that? Could you also tell me why you choose to use a creamer and Equal?

Joan: I thought a creamer was better than cream, and that Equal was better than sugar.

Clinician: Well, Joan, believe it or not, creamer and Equal can actually be worse for your health than cream and sugar. I’d like to recommend that you have some good organic cream, and instead of Equal or sugar, would you be willing to try a natural sweetener? Like honey or a few drops of stevia? There are a lot of additives in both of those products that can affect mood, and I want to rule out anything that can be affecting your mood. Since you drink coffee at work, maybe you could bring a little bit of organic cream and some stevia and keep it at the office with you.

Joan: Yes, I could do that.

Clinician: Wonderful. And from today onward I want you to consider this mantra: “Food is medicine.” This means all the food that goes into your body should be used to help you in some way. If it has no health value, then chuck it. So begin with a good low-acid coffee and cream; and cream is better for you than milk. Focus on just two cups in the morning and don’t drink unless your belly has some food in it.

Clinician: The next thing I notice is that when I review all of the liquids, you’re not getting too much liquid, and when you are, it is not ideal for your health. We know that dehydration can actually contribute to headaches and fatigue, and I’d like to rule out the possibility that this might be affecting you. Would you be willing to drink more water or herb tea during the day?

Joan: Yes.

Clinician: You might purchase rhodiola herb tea. It will give you a boost similar to coffee but it won’t make you wired or hurt your belly. I wouldn’t drink it after 3 p.m., however. Let me know when I see you next week how you respond to it.

Clinician: I do notice that a lot of the liquids you’re drinking are stimulants, and this can affect the difficulty with sleeping that you’ve been having, and I’d like us to work toward the goal of limiting the stimulants to earlier in the day; let’s rely on foods and nutrients as we continue in our discussions to support your energy. Does that sound workable for you?

Joan: Well, I guess.

Clinician: We’ll put that on the back burner for right now, but just know I think that’s the direction we’ll go in, and I promise you that you’ll notice a big difference in how you feel. I’ll work with you to find some good substitutions.

[Review goals and recommendations in the Clinician Checklist for question 2.]

Clinician: One of the things I notice in your Food-Mood diary is that there is a lot of time in between some meals. For example, between lunch and dinner is 5.5 hours or so, and the middle of the day is a challenging time for you. Your energy drops, your mood drops, you have a headache. I’m wondering whether instead of the Reese’s peanut butter cup, why not get a jar of peanut butter or almond butter and some crackers or maybe an apple or a banana. I know you like chocolate also and why not bring some organic cocoa powder to work and you can make yourself a nice cup of hot cocoa, sweeten it with stevia and use some cream or almond milk and enjoy the nut butter. You will still have the foods you like, but now they are medicinal and nutritious rather than making things worse. Does that sound like something you can do? Would you try this for the next week and then tell me how you feel; we can review that again. Would that work for you?

Joan: Yeah, I have a stove at work and a fridge.

Clinician: Great. I have a few recipes for this I will give you before you leave today. I am excited for you making these changes, Joan.

[Review goals and recommendations for question 3.]

Clinician: I notice that you eat a salad almost daily, and that is great. Do you like vegetables?

Joan: Yes, but I just don’t have time to cook or prepare them.

Clinician: I can appreciate that. Well, let’s put on our to-do list to explore some recipes that you would enjoy, that would include some more vegetables that are quick to prepare. You might even try bringing some celery to work. Peanut butter goes really nicely with celery and celery is known to reduce anxiety.

[Review question number 4.]

Clinician: Joan, I notice that you’re eating fruit cocktail and some applesauce, both of which are loaded with sugar. Apples are a perfect fruit for you. I’d like to encourage you to choose apples instead of the fruit cocktail and the applesauce because the sugar in both of those products is exacerbating your symptoms. Research shows that sugar can cause inflammation in our bodies, and this contributes to depression. Again, I want to reduce all these dietary causes of your depression, so we can focus on the life changes you want to make. Do you think that’s feasible for you to do? Could you start that this week?

Joan: Yes, I could do that.

Clinician: I know we are going through a lot here and I am making a lot of suggestions. How are you feeling at this point? I don’t want to overwhelm you, and we can stop here if you prefer.

Joan: No, this is great! It is giving me a lot of ideas. I didn’t realize all of these things.

Clinician: Joan, I am convinced that you would feel better if you were eating more protein. Brain chemicals that help us feel happy rely on protein. What are the kinds of proteins that you like? For example: chicken, eggs, fish, beans, meat . . . .

Joan: Well, I like chicken, eggs, and tuna fish. Sometimes I eat a steak in a restaurant .

Clinician: Wonderful! We talked about you eating in the morning. How about if you begin with an egg? Perhaps a soft-boiled or hard-boiled egg . . . ? Really however you like it. Even a light scramble with some butter would be fine. Some of my clients who are very busy like you boil eggs the night before and then carry a few to work. This would be ideal for you also. Also, add some chicken or salmon to your salad at lunch everyday, and then also have a little chicken or tuna for dinner. Think of the protein as energy for you. If you eat a little of it throughout the day, I guarantee you that your energy will be much stronger. If you start doing this tomorrow, when you come in next week I think you will feel very differently. Can you commit to doing this?

Joan: Yes, I can. I am starting to feel excited about these changes.

Clinician: Joan, before we wrap up for today, I want to discuss fats because they are helpful for stabilizing your energy and mood. I notice that when you have salad, you have French dressing. Do they have olive oil at this restaurant? Do you like olive oil and vinegar, or olive oil and lemon? Maybe you could check and that would be a good change to make that would begin to get you the kinds of fats that are healthy for you.

Clinician: I’m looking at these last few items on my checklist. One of the things we’re going to focus on as we move down the road is making sure you get food that’s satisfying and better quality . . . the better quality the food, the better your energy and mood. Remember your mantra: Food is medicine. Since you like to cook, I have some healthy Crock-Pot recipes (see Appendix D) that require only 15 minutes, so they will fit your schedule. We can address that more next week, but just give that some thought. Right now, let’s review some of the changes you’re going to explore this week. I will follow up with you by sending you an e-mail later listing some of the changes we discussed. I am also going to include the names of two nutrients I’d like you to purchase that will help reduce and eliminate the pain in your belly. If you can at all avoid taking the aspirin, please do.

Do you have any questions for me before we end? Let’s recap the changes you have agreed to make this week. We have identified some changes that will bring you the quickest and lasting results. I’m going to be eager when you come in next week to hear how your week went .

GOAL SETTING

The goal for the first and second assessment sessions is for the client to share her or his primary concerns and to elicit one or two goals. Additional goals may also emerge from the review of the Food-Mood diary, and the clinician can link the client’s identified goals with the Food-Mood diary and overall assessment findings.

Clients will leave with at least one action (and possibly several) they have agreed to undertake until we meet again.

Week 1 Goals for Joan

•  Eat an egg for breakfast.

•  Substitute cream for creamer.

•  Use healthy fat (olive oil) on salad.

•  Add protein to lunch salad.

•  Obtain low-acid coffee.

•  Substitute apple instead of applesauce.

•  Substitute peanut butter and chocolate and stevia for candy.

•  Reduce aspirin use.

Week 2 Goals Revealed

•  Reduce or eliminate soda pop.

•  Increase the amount of water drinking.

•  Buy a Crock-Pot to cook a chicken.

Essential Outcomes for Client Education During the Food-Mood Assessment

1. The client knows more about the connections between her or his food intake and mood and energy levels.

2. The client understands that a combination of protein, complex carbohydrates, and fats every few hours will sustain mood and energy.

3. The client understands that depression, pain, and anxiety result, in part, from inflammatory foods.

4. The client calculates a range of water/healthy fluid intake that is optimal for energy and well-being.

5. The client commits to one to three goals of nutritional behavior change than can be transformed during the first week.

6. The client has heard about some additional goals for the future weeks to consider .

INTAKE FORM INTERPRETATION (CONT.)

1. Current Health Information (Access Appendix B for the Client Intake Form)

Height/Weight Measures and Their Meaning

Some of the things that people worry about the most and that form the basis for nutritional or medical recommendations include what people weigh and the number for their body mass index (BMI) (this is a general measure of body fat based on height/weight ratio). This information can form a focus of obsessive-compulsive behavior or be useful for change. What matters is what it means to the individual, and it can often be a source of shame. While the BMI is commonly used, it is not particularly meaningful to health because where the excess weight is carried is more important. For example, I had a client who was an athlete who was 5 feet 8 inches and weighed 200 lbs. By BMI standards she would be considered obese. However, as an athlete, she carried 150 lb of lean body mass muscle and bone and was in top condition. Fortunately, our work together was not about weight loss but optimal athletic performance.

If clients are obsessive about weight and BMI, I encourage them to consider hip-waist ratio as a more effective tool if they require a measure. Moreover, I emphasize condition and well-being, focusing on active choices that improve overall well-being with less of a focus on weight per se. For these “always dieting” clients, educating them about the “Obesity paradox” is essential. The Obesity paradox suggests that being overweight or moderately obese may not be deleterious to health and that people who are ill and overweight have better mortality rates than people who are underweight. Like all epidemiological research, these findings have to be applied to the individual to be of value. However, these outcomes are relevant to our work because the “paradox” suggests that we deemphasize weight as a measure of health and instead focus on measures of health, including the reduction of systemic inflammation and oxidative stress, and improving aerobic and anaerobic conditioning and flexibility. If a client wants to measure and chart progress, a hip-waist ratio is a more accurate reading of potential health risk (see Box 3.3).

Box 3.3

Hip-Waist Ratio

To accurately measure the waist and hip ratio, follow these steps:

Place a tape measure around your bare stomach just above the upper hipbone .

Make sure the measuring tape is parallel to the floor (slanting can falsely increase your measurement). Also ensure that the tape measure is snug to your body, but not so tight that it compresses the skin. Exhale while measuring and relax your abdomen—sucking in is not allowed!

Using a tape measure, measure the circumference of your hips.

First look in a mirror and identify the widest part of your buttocks. Then place the tape measure at this location and measure around the circumference of your hips and buttocks. Using your waist circumference measurement, calculate your waist-to-hip ratio by dividing your waist circumference by your hip measurement. Divide the waist measurement by the hip measurement; a result above 0.9 for men or 0.85 for women indicates abdominal obesity and an elevated health risk.

Treatment Received, Experience With Practitioners

Understanding previous treatment and results, attitudes and experiences, benefits, connections, and mistreatment all inform our work as clinicians. I want to understand whether my client has felt heard, understood, and taken seriously, especially when the client may have been told that her or his symptoms are “psychosomatic” since the physical and mental are mediated so completely via nutrition.

Daily Activities, Stress, Pain

Understanding current levels of activity will inform possible issues of energy and inflammation and pain that are linked to nutrition. It is also important to identify what people engage in and where they may enjoy activities and receive support to return to those activities.

2. Health History

One of the most important steps a clinician can integrate is a comprehensive health history. Mental health symptoms give clues to physical problems, and physical problems also reflect emotional or cognitive issues. To understand these relationships, a health history is required.

Surgeries give insight into a variety of factors. The removal of digestive organs can occur as a response to illness, or in turn it can lead to nutrient deficits. Appendicitis may reflect chronic intestinal problems; removal of the gallbladder leads to problems digesting fats. Bariatric surgeries create absorption problems and often-lifelong deficits that must be closely managed. Thyroid surgery is also common and affects metabolism and mood. Surgery for chronic pain conditions is always linked to the inflammatory process and often linked to a history of early-life trauma. It also often follows from or leads to prescription painkiller abuse, which in turn affects one’s digestion and depression.

A history of elective surgeries may also illuminate body dysmorphia, addictions, and a history of complex traumatic stress. Elective surgeries such as liposuction or cosmetic surgeries are highly correlated with histories of trauma (Korn, 2013).

A thorough history of treatments tried, and whether or not they have been successful or failed, will also inform the choices people have made and what has worked or failed.

3. Lifestyle Factors—Physical Activity and Exercise

Physical activity and exercise is the third part of the triad of healing and recovery in mental health along with nutrition and counseling. Understanding the role of exercise in self-care practices includes the three main types of movement, including stretching, aerobic, and anaerobic (muscle strength exercises). Exercise also affects nutritional status, increasing needs, altering appetite and increasing brain NTs and hormones. Exercise is a vital part of eliminating medications and improving mood, and this is a good place to educate about that. Most people do better on their nutritional plans when they are exercising. The assessment may also provide information about obstacles or phobias about movement that can be addressed. People who are overexercising have special nutritional requirements, and chronic overexercise can be a sign of an eating disorder.

4. Family Medical History

For the purposes of a comprehensive assessment, I explore family history to identify and deconstruct belief systems about the hereditary or inevitability of a disease process. Reviewing family history gives insight into family belief systems and behaviors and can be incorporated into exploring faulty beliefs. While there are some hereditary diseases and genetic vulnerabilities (like celiac disease), few are inevitable. Generally, most illnesses, both mental and physical, are lifestyle related and stress related, and even genetic illnesses are epigenetic in nature. They are not necessarily inevitable, but many are “triggered” by environmental stressors that can be prevented or reduced in severity. Family medical history and treatment also sheds light on family beliefs related to use of medications, fear of medications, or other behaviors that will influence the client’s choices .

5. Current Dietary Habits

Understanding current diets and the decisions and beliefs underlying those choices and behaviors is central to developing a nutritional plan. A client may be open to new options or ironclad in his commitment to his current diet. Often the client is following a diet that is not appropriate for the specific biochemical individual needs, and this provides an opportunity to educate about areas for change. I also ask about eating behaviors, including meal/snack patterns, eating style, eating with people or alone, and behavioral issues like dining out (e.g., what kinds of places?).

Food Allergies/Sensitivities—Known and Suspected

In Chapter 5 , I review in depth the role of food allergies and sensitivities and their contribution to mental illness. Here is where you might explore if any testing has been done. People may know of allergies/sensitivities or may suspect them but have never been tested or conducted an elimination diet. The question about “foods that you could not give up” reveals potential obstacles to dietary change.

Current Food Preparation Methods

This section explores activities surrounding food gathering and preparation. Both past and present practices will illuminate strengths and obstacles. People who have cooked in the past will more easily start again, while people who have not enjoyed cooking or are afraid of cooking will pose different challenges than those who have never learned but would like to. The answers in this section will guide “cooking coaching” options outlined in Chapters 6 .

6. Diet History

Early dietary experiences can set the stage for childhood and adult physical and mental illness. These experiences can influence the willingness as well as the knowledge base that will inform adherence and compliance. Understanding the types of foods an individual is used to eating, as well as what foods she grew up on, will reveal dietary habits that may be difficult to change.

For example, did the client’s mother eat a diet rich in essential fatty acids? Was the client fed formula? Did she experience ear infections? How about the use of antibiotics? This history could expose the possibility of dairy sensitivity and microbiome imbalance .

Digestive Problems Currently, During Childhood, and During the Teen Years

Did the client complain of stomach pains during childhood? Acne can be associated with food sensitivities to dairy. When did the symptoms of eating disorders begin? Were they resolved, or are they current, and how have the symptoms changed?

History of Fasting, Purging, History of Binging/Purging (SAD or Triggers)

Fasting, purging, and binging provide insight into chronic or acute responses to stress and nutrient deficits. Understood in context, these practices reveal where healing should be focused. Someone who fasts for a day a week because he believes in the calorie restriction theory of longevity is assessed differently than a young woman who had decided to fast for 10 days on water to lose weight. Even purging, while not a commonly practiced behavior that we see outside of pathology, has a long history as part of religious and health rituals around the world. Thus, a client who discusses purging as part of her spiritual or consciousness practices must be understood in the context and outcomes of these practices. Overall while fasting, binging, and purging are often associated with eating disorders, like all behaviors they must be understood for their meaning and outcomes.

Where there is a history of chronic binging and purging in particular, nutritional status should be evaluated immediately and treatment initiated.

History of Meals, and Mealtime, Current and in the Past

This section will reveal potential strengths and obstacles to engaging in a program of self-nourishment. Was the client a “latch-key” kid? Did he cook for himself and brothers and sisters? Was there fighting at mealtime? Were foods prepared from packages or homemade, or were they special types of meals? What about low-fat substitute use? Is she a practicing vegetarian? Is her diet based on religious or spiritual beliefs?

7. Medications: Current and Past Use

In mental health intakes we collect information on psychotropic medicine use. However, in the integrative assessment we collect information on all the medications a client is using, as well as herbal preparations, vitamins, and minerals. It is essential that all use of medications, including prescription, self-prescribed, and recreational or abused medications, be identified. Why is this important? One, there can be complex drug-nutrient-herb interactions. For example, fish oil is a blood thinner; if a client is already taking a blood thinner, it is important to know. Knowing what the complete medication list contains may also prompt collaboration with the prescribing clinician. For example, you may feel that 3 g of fish oil is useful for your client’s depression, but he may already be taking a blood thinner. Taking high-dose fish oil can help thin the blood and actually may even reduce the dosage required of a blood thinner; however, this kind of recommendation should be coordinated with the prescribing clinician.

A number of approaches to improving mood stability involve nutrients that can lower blood sugar; clients with diabetes who may be on blood sugar–lowering medications such as metformin or insulin will want to be advised of the potential effects of these helpful nutrients in order to prevent blood sugar from going too low. This subject is explored further in Chapter 8 .

Past Use of Medications—Pharmaceuticals, Antibiotics

Address drug-nutrient-herb-food interactions.

8. Use of Nonpharmaceutical Substances

What and how people use medications or substances to self-medicate also gives insight into the options we will suggest. Some clients will begin by withdrawing from substances, others may have done so years before, and still others do not want to take any supplements. Some may present a list of 20 items they take and have significant beliefs and associations about their benefits. Still others have prescriptions from multiple clinicians. I call these “serial clients”; they will move from clinician to clinician without always following recommendations, or they have many at once and compare and contrast what each says. All of this will contribute to our understanding of how to coach clients and make recommendations.

With a list of all medications and substances, one can evaluate their interactions by using an online database and explore potential nutrition deficits or dangerous interactions. There are many excellent databases identified in Appendix Z .

9. Use of Nutritional Supplements and Herbs

The main purpose of this section is to identify whether someone is already taking nutritional supports and at what level. If the client is not taking any supplements, that is as informative as the individual who has a comprehensive plan underway. The source and quality of the nutrients are very important as poor-quality supplements have fillers, additives, sugar, and food colors, so often the place to start is improving the quality of the supplements. Who, if anyone, prescribed them? What are the dosages, and are they adequate or excessive? What is their potential for negative interactions with medication? Assess their efficacy relative to current goals.

10. Detoxification Section

Types of detoxification the client has undergone or tried, currently and previously.

This section provides insight into the spectrum ranging from self-care to self-harm. It is as important to know what people are doing as well as why they are doing it. Detox fads make the rounds just as do dietary and food fads. Elsewhere I have written extensively on detoxification and the scientific basis for its benefits (Korn 2013). There are significant benefits to detoxification when done correctly; however, some transient nutritional harm can result at times if done incorrectly or for long periods. I also want to understand if these behaviors are linked to mental health or undue concerns about feeling dirty or unclean, and integrate this understanding into our work toward health.

11. Pain and Discomfort

Pain levels can be assessed using the visual form and the visual analogue. Pain provides insight into inflammation levels; it often co-occurs in depression, either as a co-occurring or a secondary result of living with pain (a hallmark of fibromyalgia). The potential to reduce pain may motivate a client to change her diet. This is accomplished by eliminating inflamatory foods and increasing anti-inflamatory foods and nutrients. If pain is a primary concern, it can be the focus of initial dietary and supplement protocol.

12. Current and Previous Medical Conditions and Their Link to the Mental Health Nutritional Checklist

In this section people may again consider symptoms they experience.

Headaches

What types and how often, and what seems to trigger incidents? Gluten and food allergies are major triggers for headaches; use of medications for headaches can cause digestive problems.

Fatigue may signal nutrient deficiencies or signal chronic stress/hypoglycemia. Infections and sinus symptoms may signify food allergies, especially to dairy .

Skin Conditions

Chronic rashes and fungal infections may indicate high levels of sugar consumption or low essential fatty acid levels.

Allergies

Allergic reactions to scents, oils, lotions, and detergents may signal chemical sensitivity, which may reflect chronic stress response and adrenal fatigue. Clients should be encouraged to eliminate these exposures.

Muscles and Joints

Somatic signs of stress signify inflammatory levels and food allergies; pain may point to inflammation also underlying depression and other cognitive symptoms. Such symptoms may indicate the need for dietary anti-inflammatories.

Nervous System

Head injuries, concussions, dizziness, ringing in ears, loss of memory, confusion, numbness, tingling, sciatica, shooting pain, chronic pain, depression, and other similar responses.

There is a range of implications for cognitive function and inflammatory process in the body. History of head injuries can contribute to chronic headaches and be a risk factor for depression and cognitive decline.

Respiratory and Cardiovascular

These symptoms will likely necessitate a referral or collaboration with the prescribing practitioner. Thiamine may be used to increase blood pressure in people with low blood pressure. Supplemental fish oil can enhance circulation; sleep disorders such as sleep apnea are risk factors for cognitive decline. Hyperventilation may signal anxiety.

Digestion/Elimination

Identifying symptoms in this section will clarify digestion from “top to bottom.” Symptoms can be prioritized and addressed with dietary and supplemental nutrients.

Endocrine System

Most answers in this area will alert to the need for collaboration or a referral .

Reproductive System

Reproductive organ symptoms are often associated with poor mental health either as cause or reaction. Significant improvements can be obtained with nutritional therapies. For example, vitamin D is associated with reduction of fibroids in perimenopausal women.

Cancer/Tumors

History of cancer or current cancer may signal the need to collaborate with other clinicians.

13. Meaning of Food

The meaning of food in the client’s life may be revealed in a discussion of the food diary. Food means something to everyone and people have a variety of associations. Understanding these associations will aid change or present barriers. The meaning of food is especially important during the exploration of eating disorders or for a bariatric assessment. Food may be explored in the context of types of foods, and their positive or negative associations with how foods are used for energy, for self-medication, relaxation, and in the context of early or current family life.

Sometimes clients live alone and do not prepare food for themselves or do not have time to cook. Or, people may have a difficult time answering this question. At this stage, there may be an opening to understand food-related behaviors and discuss the role of mindfulness and eating.

This is also a good stage in the intake to take a break and teach your client the mindfulness exercise discussed in Chapter 2 .

14. Motivation for Nutritional Change/Obstacles

This section explores areas and activities where the client has previously been most successful, what has not worked, and the challenges/obstacles. This will provide insight into special areas for focus.

Identify the differing needs within the current family, history of cooking, and so on.

What is currently working? What are the obstacles to change? (See nutritional change questionnaire at the end of the Client Intake Form.)

There can be a number of factors, including biochemical individuality. Not everyone in the family needs the same kinds of foods in the same amounts, but oftentimes one person will sublimate her or his needs to the other without realizing its detrimental health effects .

The information gathered here can be used further when we explore “putting it all together” for coaching in Chapter 9 .

NEXT STEPS FOLLOWING THE INITIAL INTAKE AND ASSESSMENT

Once the intake is complete, the clinician will review it and analyze it in preparation for sharing results and ideas for prioritizing next steps. It is important to collect information about the financial resources a client has available to allocate to a nutritional program since food and nutritional supplements can add up to several hundred dollars a month. Understanding the client’s own timeline for change is also useful as it helps to gauge the rate of change that will be established during goal setting. The development of a report and identifying change strategies are found in Chapter 9 .

Before any assessment is complete, however, there are additional factors that must be integrated into the analysis. Assessment of mental health and nutritional status is not a linear process. It is an ongoing process of integrating the many factors affecting the way nutrition and dietary behaviors contribute to our individual client’s well-being. Here we transition away from the particulars of the individual to incorporate factors that intersect with nutrition that are absolutely essential to understanding the underlying causes of mental illness. In Chapter 4 you will find I apply these factors to specific diagnoses, and in Chapter 7 I review treatment strategies.

Five Essential Mental Health Nutritional Factors to Assess in Everyone

Many similar damaging processes result in a variety of symptoms and different diagnoses. This requires that we assess five essential factors that underlie poor mental health and that are caused by poor nutrition and can be addressed by nutritional therapies. Next I describe these factors and in subsequent chapters I describe the range of interventions that treat these five essential factors.

People come into the world with various strengths and weaknesses that can be genetic and also result from in utero and perinatal exposures. Early-life patterns and life stressors can strengthen or exacerbate these genetic patterns. Not all “genetic propensities” are necessarily evident. Environmental toxins and, most important, nutrition can activate dormant genetic responses for good or for ill. This is called epigenetics.

Consider what happens when a brand-new car is exposed to salt on the road every winter for several years. The original fine sheen begins to rust; at first perhaps a small area on the fender, then the hood has a larger area, and then rust breaks through the metal floor and spreads. Your neighbor’s car, however, is exposed to the same salt, but the rust doesn’t seem so bad, or it starts near the hubcaps. Meanwhile the tires on your car are wearing thin a bit sooner than your neighbors, even though they have the same mileage. Step by step the systems required for the car to function suffer; this depends upon the year of the car, its original quality, and its history—maybe it was mishandled in an accident at the factory, or perhaps your neighbor’s car was garaged while yours was not. It is these many variables combined with the care or neglect and the various types of exposures that will determine the unique ways in which the car begins to break down. The human mind and body are not so different.

All of these five essential factors directly influence mental health and must be assessed in the context of each individual’s specific responses.

Five Essential Factors That Affect Mental Health

1. “Chrononutrition” imbalance

2. Blood sugar and functional hypoglycemia

3. Food sensitivities, especially gluten/casein sensitivity

4. Inflammation, including mitochondrial energy and oxidative stress

5. Methylation: conversion of folic acid (B-9) to l-methylfolate

Essential Step 1

Assess for chrononutrition imbalance. Chrononutrition refers to the dynamic relationship between the timing of food intake and nutrient deficits; the sum total of these effects on circadian rhythm underlies mental health. As with other conditions, diet supplementation and food behaviors can rebalance circadian rhythm and thus contribute to improved mental health.

Think of a major clock in the brain that is linked to the great “clock” of daytime and night time, of light and dark. This master clock then regulates other smaller clocks in the body that in turn regulate digestion, glucose handling, and hunger. Mood disorders occur when the “brain clock” is out of sync with the master clock of light and dark, and in turn this dysregulates the smaller clocks. Thus, to reset these clocks so they are all synched, we use being awake, sleep light and dark therapies, and nutritional therapies that help move the “hands” of the clock backward or forward.

Circadian rhythm significantly influences depression, anxiety, PTSD, chronic pain (fibromyalgia), menstrual problems, OCD, bipolar disorder, eating disorders, and insomnia. Medications, nutrients, and light exposure can all affect adversely or beneficially the sleep-wake cycle and mood. Early-morning wakening, morning depression, chronic sleeping in late, awakening with exhaustion, feeling wired at night, and using medication to sleep are all signs of circadian rhythm disruption.

Stress alters the circadian rhythm and cortisol levels, which affect sleep, wakefulness, and fatigue. Excess cortisol can reduce sleep quality and duration, and circadian rhythm governs the rise and fall of amyloid-beta production, which is implicated in the development of Alzheimer’s disease. Sleep deprivation is a risk factor for the development of dementia (Kang et al., 2009). Night shift workers are more vulnerable to stress-related illnesses, including depression and anxiety (Bara & Arber, 2009) and cancer.

Assessment Essentials for Circadian Rhythm

Review sleep-wake cycle.

24-hour salivary cortisol test : This at-home test measures cortisol at four data points. Cortisol follows circadian rhythm and provides insight into the relationship between stress, adrenal function, sugar handling function, and the sleep-wake cycle.

Automated Morningness-Eveningness Questionnaire (AutoMEQ) : This 19-question assessment provides information about sleep habits and your circadian rhythm type (see Appendix Z : Resources).

Essential Step 2

Assess blood sugar handling and eliminate functional (reactive) hypoglycemia. The next most important function to assess is blood sugar handling, functional hypoglycemia, and hyperglycemia/diabetes. Most everyone with mood lability has poor glucose handling. Without evaluating blood sugar handling, we will not know truly what is causing mood lability. Hypoglycemia causes significant mood lability that can appear to be anxiety, bipolar disorder, irritability, ADHD, or affective dysregulation. Chronic stress gives rise to hypoglycemia, which in turn leads to these many symptoms. Blood sugar levels are also intimately related to circadian rhythm and adrenal function so that people with chronic stress often have reactive hypoglycemia, which can develop into type 2 diabetes. The role of blood glucose and its effect on mental function has been a focus over the last 30 years with the rise of type 2 diabetes and mood lability in children and adults alike. What occurs in the body occurs in the brain. The term “diabetes type 3” (de la Monte & Wands, 2008) was coined to reflect the new understanding that Alzheimer’s disease is a type of diabetes of the brain associated with diets high in refined carbohydrates .

Assessment Essentials: Blood Sugar Handling and Hypoglycemia

1. Identify the daily use of refined carbohydrates and sugars, low protein intake, long periods between meals or using refined carbohydrates every few hours to sustain energy, and periods of sleepiness during the day. These are all signs of functional hypoglycemia.

2. Assess for functional or reactive hypoglycemia by conducting a review of the Food-Mood diary, especially questions 1, 3, 6, 8, and 10.

3. Review the following checklist of major symptoms of hypoglycemia and poor blood sugar handling:

Dizziness

Feeling shaky

Confusion

Hunger

Agitation

Crying

Headache

Irritability

Rage

Tired

Inability to focus

Pounding heart; racing pulse

4. Following the hypoglycemia diet (see Appendix A for General Guidelines for a Hypoglycemic Diet) for 1 week is also a “rule-out” method. People with functional symptoms will feel much better when following this diet.

Essential Step 3

Assess for gluten/casein/food sensitivity/allergy. Celiac disease, nonceliac gluten sensitivity, and casein sensitivity are all important causes of mental illness. Significant clinical evidence has established casein and gluten sensitivity in people with mood disorders, anxiety, major depression, and schizophrenia (Cascella et al., 2011; Samaroo et al., 2010). People with bipolar disorder (Dickerson et al., 2012), OCD, autism, ADHD, and eating disorders have been found by practitioners to react to gluten and casein.

Gluten is the protein found in certain grains (wheat, barley, and rye) that causes grains to “glue” together. Gliadins are proteins that are components of gluten. Celiac disease affects about 1 in 250 people and is an autoimmune disease that manifests in severe digestive and frequently neurological symptoms. Nonceliac gluten sensitivity is an immune response leading to both digestive and neurological problems (Jackson, Eaton, Cascella, Fasano, & Kelly, 2012) but may not manifest in digestive distress and thus may go undiagnosed.

Casein is the protein found in dairy milk products. Both gluten and casein contain proteins to which people may be either allergic or sensitive. About 50% of people who are sensitive to gluten are sensitive to casein. This is called “cross reactivity.”

Assessment Essentials

There are two basic approaches to assessment: the elimination diet and blood and/or salivary tests. Testing for both celiac and the various antibodies to gliadin and other gluten protein or an elimination diet should be enacted as a first step.

There are different tests for nonceliac gluten sensitivity; one assesses blood and the other saliva. Comprehensive testing should include testing for antibody production to a variety of proteins, enzymes and peptides including Transglutaminase, Deamidated Gliadin, Glutenin, Gluteomorphins/Prodynorphin, Wheat Germ Agglutinin, and foods that are Cross- reactive to gluten.

Adherence to a gluten- and casein-free diet is challenging for many people, especially children. Thus, it is important to conduct highly specific testing. New tests are available for both urine and serum and extend immune system testing to include the testing of peptides, which act as undigested proteins contributing to gastrointestinal, neurological, and neurodevelopmental disorders. These neuropeptides called casomorphins and gliadorphins act like opiates in the brain; they affect cognitive function, speech, and auditory integration and decrease the ability to feel pain. For example, binging associated with bulimia is linked to gluten sensitivity, which releases opioid peptides, accounting for the binging/withdrawal response to grains, especially wheat. Cravings for wheat and grains are often associated with mood elevation upon eating these foods.

Celiac disease: The standard test is called the tissue transglutaminase antibodies (tTG-IgA) blood test for antibodies to gluten.

Gluten/casein intolerance : Some labs conduct highly specific tests that analyze up to 24 possible substances that affect digestive immunological and brain health, including gluten/casein intolerance.

Urinary/serum peptide tests : The gluten/casein peptides test determines the effects of sensitivities to the opiate-like peptides in response to gluten or casein, even if an individual has no IgE or IgG allergic reactions (see Appendix Z : Resources).

Assessment With the Elimination Diet

It is not always practical due to financial resources to undergo blood or salivary testing. I recommend these tests to clients while remaining aware that they may not always be affordable. In this case a diet that eliminates all exposure to gluten and casein can be used. Gluten is found in many foods, not just bread products, and the elimination diet must be exacting. I recommend eliminating gluten first. It takes at least 4–12 weeks to experience the effects (see Appendix E for a comprehensive list of gluten-containing foods). Following the gluten elimination diet, I recommend the casein (dairy) elimination diet since gluten and casein cross-react about 50% of the time.

Essential Step 4

Assess inflammation, oxidative stress, and mitochondrial energy. Oxidative stress occurs as a function of living, just like a car rusts and ages over time. One theory of aging is the rate at which one “rusts.” Thus, we assume some oxidative stress and mitochondrial dysfunction based on aging and symptoms alike. Oxidative stress is similar to when your car becomes rusty. Over time, if the rust is not addressed, it affects the little engines that fire up the car (the mitochondria inside the cells); as a result, they in turn cannot convert nutrients into energy. Mitochondrial dysfunction is involved in depression, bipolar disorder (Stork & Renshaw, 2005), Alzheimer’s disease, schizophrenia (Jou, Chiu, & Liu, 2009), chronic fatigue, and fibromyalgia. Chronic alcohol and drug use, and poor-quality diet leads to oxidative stress. Chronic stress damages mitochondrial function in response to chronically high glucose levels (Picard, Juster, & McEwen, 2014) that in turn lead to systemic inflammation to neuronal damage and cell death.

Assessment Essentials

In addition to the mental health symptoms I have discussed earlier, pain, heat or inflammation around joints, along with cataracts, and heart disease are signs of inflammation. Oxidative stress precedes neurological diseases and mitochondrial energy failure occurs in fibromyalgia and chronic fatigue.

Basic inflammatory markers in blood tests

Homocystein e

High-sensitivity C-reactive protein (CRP): norms, under 0.55 mg/L in men and under 1.0 mg/L in women

Fibrinogen: 200–300 mg/dL

(See Appendix Z : Resources)

Telomere testing: Telomeres are genetic material at the end of each chromosome. Their primary function is to prevent chromosomal “fraying.” Think of the plastic tip at the end of a shoelace that keeps the shoelace from unraveling. It is normal for telomeres to shorten over time with age, leading to cell death. The oxidative stress hastens this death just like rock salt hastens the rust buildup on a car in New York City, in contrast to the same car with no salt garaged in Arizona. A variety of stressors appear to cause telomere damage, including overconsumption of sugar and chronic stress in early life (Mitchell et al., 2014). Telomere length appears to be influenced positively by intake of antioxidants that combat oxidative stress (Shen et al., 2009). Testing telomeres can reveal the effects of oxidative stress on DNA (see Appendix Z : Resources).

Essential Step 5

Assess methylation: conversion of folic acid (B-9) to I-methylfolate. A significant number of individuals lack the ability to convert folates (or its synthetic form folic acid [B-9]) to l-methylfolate, due to natural genetic mutations. The process of folate conversion requires an enzyme called MTHFR (5,10-methylenetetrahydrofolate reductase) to convert folic acid and food folate into 5-methylenetetrahydrofolate. This processing deficiency is quite common among patients with depression (Rush et al., 2006), and up to 70% of patients with depression test positive for the inability to convert folic acid into L-methylfolate. This renders folic acid in vitamin B supplements and enriched foods ineffective for this group of patients. This leads to problems in what is called the “methylation pathway.” Defects in methylation conversion pathways set the stage for a variety of symptoms due to the body’s inability to metabolize specific vitamins and NTs like dopamine, necessary for physical and mental health. One of the signs of folate (and vitamin B12) deficiency and a possible MTHRF mutation is elevated homocysteine levels—a risk factor for both depression and cognitive decline.

Methylation Pathway

Orthomolecular clinicians consider the role of either overmethylation or undermethylation processes in the contribution to psychiatric illness. Different nutrients increase or decrease methylation. Methylation pathway problems contribute to high homocysteine levels, which are a marker for both heart disease and depression. The methylation pathway is also responsible for the synthesis of CoQ10 in the body.

CoQ10 is required for mitochondrial energy production. Fibromyalgia and chronic fatigue are two signs of methylation dysfunction that benefit from B vitamins. The body must convert folates into a usable form. Folates are found in plant foods, such as spinach, or in the synthetic form called folic acid found in multivitamins, and in “enriched” flour or other processed foods. Folic acid or folate is routinely administered to pregnant women to prevent neural tube defect. There is a correlation between low levels of folate and poor response to SSRIs, which had led to folate/folic acid supplementation to improve the efficacy of SSRIs. Diets high in folates, such as the traditional Chinese diet, are linked with lower lifetime rates of depression (Korn, 2013).

Assessment Essentials

High homocysteine levels indicate that the methylation process is inadequate.

MTHFR mutation is a simple blood test that is widely available and generally covered by insurance (see Appendix Z : Resources).

Lab work: Completion of the history and specialized assessments will also lead to a discussion of further testing that may involve lab work. Some people want lab work right away, and others may not for reasons of affordability. A great deal of improvement can be achieved without specialized lab work, and thus its costs and benefits should be discussed with the client. I will suggest to a client that if results are not obtained following 3–6 months of dietary and nutrient changes we will explore laboratory testing.

DIAGNOSTIC AND SYMPTOM-SPECIFIC ASSESSMENTS

Following a review and analysis of the overall assessment, symptom-specific assessments may be incorporated. In the following section I address eating disorders and bariatric surgery because so many people seek help with eating issues and because eligibility for bariatric surgery requires a psychological assessment. In Chapter 4 , I continue exploring nutrition and the contribution of nutrient deficits to specific diagnostic categories.

Eating Disorders

People come for counseling and nutritional therapies to talk about chronic or acute eating disorders. They may also want to be evaluated for bariatric surgery. Frequently a discussion of food behaviors surfaces during the treatment of depression, anxiety, or PTSD when self-care habits are associated with a sense of helplessness. To obtain bariatric surgery a client requires a psychological review. A clinician who understands mental health nutrition can be a vital resource to the client before, during, and after surgery.

Anorexia nervosa (AN), bulimia, and binge eating disorder (BED) affect all ethnicities in the United States. Latinos and African Americans tend to have higher rates of bulimia nervosa (BN). Bariatric surgery patients have a 27% lifetime prevalence of BED (Herrin & Larkin, 2013). There is a high rate of eating disorders among women and men who were victimized in childhood (Korn, 2013). There are elevated levels of anxiety and depression among bariatric surgery candidates and higher rates of mental disorders among the obese and then even higher rates of mental disorders in obese people who seek bariatric surgery (Mitchell & Zwaan, 2011). Bisexual and gay men have a higher risk for eating disorders with as many as 15% (Herrin & Larkin, 2013). Eating disorders are highly comorbid with obsessive-compulsive disorder, and the nutritional treatment is very similar. Balancing serotonin levels is central to the range of symptoms that occur along the eating disorders continuum.

Eating disorders reflect complex psychobiological stressors, efforts to regulate affect through food and food behaviors, and complex nutritional imbalances. Eating disorders often have a dissociative and obsessive-compulsive component. At a larger social level are the influences of pressure and advertisements on children and adults of what constitutes a perfect body and the ways that food or lack thereof may achieve that. Eating disorders often co-occur with orthorexia, which I explain in Chapter 5 .

The eating disorders in general are linked to dissociation and alternate states of consciousness achieved through food types and binging/fasting/purging activities. Bulimia and purging are anxiolytic behaviors. For example, purging activates vagal response. If you have ever thrown up, you know that afterward you are exhausted and fall asleep. Indeed, there are many cultural practices throughout the world that actively engage purging and regurgitation as methods of altering states of consciousness. People generally use carbohydrates as their food of choice in bulimia, though they can choose fatty foods as well. These are mood altering by way of the serotonergic system, but they also lead to a sense of fullness.

People who often engage in fasting and or purging frequently engage in intensive exercise. Or, as regulation of food intake becomes more balanced, intensive exercise can increase. These behaviors alter consciousness by inducing endorphin response, which reduces anxiety, but it can also exacerbate dissociative symptoms. Foods themselves have psychoactive components, which are enhanced when there are allergies or sensitivities, for example, to the opiate-like chemistry of gluten and casein that affects many people with eating disorders.

Bulimia Nervosa

Bulimia nervosa (BN) tends to include impulsive and secretive behaviors, as well as mood lability (Herrin & Larkin, 2013). Higher rates of BN are found in those with a history of trauma. The difference between BN and BED is that bulimics will compensate for the binge by self-induced vomiting or other measures like exercising excessively, restricting their food intake, or excessive intake of diuretics and laxatives (Herrin & Larkin, 2013).

Purging Behaviors

AN and BN behaviors both may include purging and extreme use of laxatives, which upset the digestive process and also the health balance of intestinal flora. Chronic purging can be dangerous and lead to nutritional deficits, GERD, and even death. Most eating disorder treatment approaches have a goal of eliminating purging behaviors, including self-induced vomiting. However, not all purging behavior is harmful, and frequency and the meaning of the practice should be assessed with each individual. Historically and across cultures humans (and other animals) are known to engage in these ritualized behaviors. Thus, understanding the spectrum of these behaviors ranging from adaptive and healthy to maladaptive and leading to self-harm and, in particular, the cultural context, will be valuable.

Binge Eating Disorder

BED may include grazing patterns where people eat small amounts of food throughout the day. Compulsive eating is similar to grazing in that eating may continue for hours; there is a tendency to repeatedly reach for food and feel overfull and out of control, and to become preoccupied with eating. It is not uncommon that individuals with BED and BN have blood sugar imbalances related to excessive starchy carbohydrate intake and insulin resistance. These are especially associated with cravings for these kinds of foods. They can never be satisfied as long as they are fed with refined carbohydrates. Grazing patterns can be interrupted or reframed when applied to hypoglycemia, which should be ruled out .

Emotional Eating

Emotional eating occurs as an effort to regulate stress or boredom or other uncomfortable emotions. Comfort foods are part of emotional eating—often high carbohydrate or high fat because both increase relaxation.

Night Eating Syndrome

Night eating syndrome is distinguished from BN and BED by the timing of food intake and the fact that the food is eaten in small repeated snacks rather than true binges (O’Reardon, Peshek, & Allison, 2005). It also does not include purging behaviors.

Anorexia Nervosa

AN is a disorder of starvation that leads to malnutrition and often death. When addressing nutritional support for AN, it is important to distinguish between pre-AN deficits and the nutritional biochemistry arising out of long-term AN behaviors and nutrient losses. Thus, a history alongside testing will reveal current nutritional status. Common nutritional deficits are low levels of zinc and potassium. Hormonal disruption, amenorrhea, and osteoporosis are also major complications. Epling & Pierce (1996) suggest that the concept of “activity anorexia,” which co-occurs at a high rate with AN, is characterized by an increase in exercise in response to a decrease in food intake that can lead to starvation and death. This suggests the need to include an exercise history alongside food history during the assessment process.

Avoidant/Restrictive Food Intake Disorder

Known also as selective eating disorder (SED), it is an eating disorder that prevents the consumption of certain foods.

Assessment Essentials

The night eating syndrome (NES) questionnaire is used to screen (with a score of 30) as the cutoff for bariatric surgery (Mitchell & Zwann, 2011, p. 44).

NES history and inventory are available from Allison et al. (2008).

Eating Attitudes Test 26: This test can be used for education and screening. A score of 20 or greater implies the need for further assessment (http://www.eat-26.com/)

Blood tests include the following :

Food sensitivities testing

Nutrient status tests

Salivary test

Zinc taste test : The zinc taste test is a simple way to test functional deficiency, which is common in eating disorders. Take a teaspoon full of liquid zinc (see Appendix Z : Resources) and you will find that you experience varying tastes based on your body’s current needs. If you are deficient in zinc, the liquid will taste like water, while if you have adequate levels it will taste bitter.

24-hr cortisol test to evaluate HPA axis function

Amino acid levels testing (urinary and blood)

Tissue mineral analysis

The Bariatric Client

Bariatric gastric bypass surgery restricts food intake by making it difficult to ingest large amounts of food. Its efficacy, however, is based on altering the appetite to decrease hunger and increase satiety and not the food restriction itself. Predicting who will be successful in losing weight and maintaining weight loss in those who undergo this surgery is difficult, and recent research identifies genetically based variations affecting success (Hatoum et al., 2013).

Weight-loss surgical procedures are categorized into three groups: (1) the laparoscopic adjustable gastric band, (2) the Roux-enY gastric bypass, and (3) the sleeve gastrectomy (Mitchell & Zwaan, 2011). Malabsorption of macronutrients is more common in these combination procedures.

A client is required to undergo a psychological assessment prior to acceptance for bariatric surgery. Most people consider bariatric surgery after many years of attempted weight loss. Nevertheless, every effort should be made to combine a weight-loss program with exercise and adjunctive methods to improve well-being. Differentiation should be made between morbidly obese individuals (BMI over 40) who have life-threatening conditions associated with obesity and the population of people with a BMI of 30–35 who wish to undergo surgery.

From a mental health nutrition perspective, bariatric surgery should be the last resort; bariatric surgery frequently leads to complications, including impaired nutritional status due to malabsorption syndrome as well as psychological sequelae. However, there are clients for whom it represents a viable alternative to improving health. Thus, it is up to the clinician to use all the tools at her or his disposal to provide an integrative approach .

Clients who are both obese or morbidly obese (and who may or may not have type 2 diabetes) may be advised by a health professional to undergo bariatric surgery, or a client may raise the option of surgery with us during treatment. Over 100,000 bariatric surgeries are performed annually in the United States. There are many types of surgeries. They range from reversible to permanent procedures. The lap band reduces the size of the stomach by sectioning off a portion with an adjustable (and reversible) gastric band. Gastric bypass may be performed, which surgically reroutes food to the lower intestine.

There is a high rate of complications post surgery and during the years following surgery, requiring specialized and ongoing management. Furthermore, a range of studies demonstrate there is significant weight gain in 50% of individuals within 2–5 years following surgery. For some people the surgeries are very successful and lead to improvement or elimination of type 2 diabetes and sleep apnea, and for others they are less successful. While a number of studies have identified some of the psychological predictors of success, they are inconclusive. Substance abuse and psychosis are among the contraindications. A number of studies demonstrate significantly high rates of self-reported childhood maltreatment emotionally and sexually among male and female obese individuals seeking bariatric surgery. Noncompliance with postsurgical requirements is high. A number of studies have identified high rates of post–bariatric surgery psychiatric hospitalization and suicidality among childhood sexual abuse survivors (Clark et al., 2007).

Where people with BN or BED seek bariatric surgery, an assessment should include a history of exposure to complex trauma. There are high rates of traumatic stress and developmental trauma disorders leading to higher rates of somatic symptoms. Caution should be taken to ensure that bariatric surgery is not suggested as another in the list of surgeries in the attempt to "cut out" the trauma that is held in the body memory. Likewise, assessment for eating as a self-regulation, self-medication method should be addressed prior to bariatric surgery. Food, carbohydrate, and fat addiction, in particular, should be assessed as well.

People will come to bariatric surgery after trying other forms of surgery such as liposuction or cosmetic surgery. These clients can also have body dysmorphia or body image issues. Bariatric surgery will not solve any of the underlying issues that may contribute to BED; indeed, it can make them worse.

A comprehensive assessment can define whether an individual is a candidate from a mental health nutrition perspective. Because bariatric surgery is a business, a therapist must serve as an advocate for the client, and the nutritionally oriented therapist can provide alternatives to surgery that have not been considered previously .

While a client may be a candidate physically and in need of weight loss, not all clients will do well, especially people who are compulsive eaters, unless they can manage the day-to-day changes that will be required for a lifetime. Furthermore, food addiction often transforms into alcohol abuse or other addictive behaviors. Where compulsive eating and being overweight are associated with a history of childhood sexual abuse, weight loss can trigger memories and flashbacks and it is advisable to address childhood trauma prior to surgery. Many people show improvement in physical health and self-esteem due to weight loss, yet many continue to struggle psychologically (Kubik, Gill, Laffin, & Shahzeer, 2013). Bariatric surgery patients show higher suicide rates than the general population (Peterhänsel, Petroff, Klinitzke, Kersting, & Wagner, 2013).

A comprehensive assessment that results with recommendations for surgery should lead to an individualized treatment plan that is strengths based, improves resilience, and engages social supports, while exploring obstacles and strategies for postsurgery adaptation (Mitchell & Zwaan, 2011).

A qualitative interview should include comprehensive weight and diet history, general eating behaviors, history of past or present eating disorders ( DSM-V ), BED (which is the most common reason people come to bariatric surgery), purging or compensatory behaviors, night eating syndrome, emotional eating, exercise, substance abuse, trauma history, treatment history, stressors and coping skills, and social supports. The intake form provides sections for all of these areas. The assessment should include psychoeducation about the surgery and postsurgery nutrition and include expectations of surgical outcomes.

A comprehensive nutritional assessment should be undertaken prior to surgery including nutrient status. This can be done with laboratory workups with a registered dietician or other professional. While bariatric specific recommendations focus on thiamine, vitamin B12, folate, iron, calcium, zinc, and vitamin D, a more comprehensive nutritional analysis outlined in this book will benefit the client along with specialized food allergy/sensitivity testing, especially given the high rates of gluten sensitivity found in bulimic clients. Specialized blood tests are available that can measure vitamin mineral status prior to surgery (see Spectracell in Appendix Z : Resources), and a client can elect to optimize nutritional status. SIBO is common post bariatric surgery and attending to gut health in advance is essential.

Following a comprehensive evaluation, the clinician can provide a report to the bariatric medical team or make recommendations for mental health treatment required prior to surgery, for example, if there is a mood disorder. The client may also require further education about the lifestyle changes required post surgery. Suggestions to attend a post-bariatric surgery support group may also be beneficial .

Assessment Essentials

Weight and Lifestyle Inventory (WALI) (Wadden & Foster, 2006)

Boston Interview for Bariatric Surgery (Sogg & Mori, 2009)

Cleveland Clinical Behavioral Rating System (Heinberg, Ashton, & Windover, 2010)

Micronutrient tests (blood). These tests measure the function of 35 nutritional components, including vitamins, antioxidants, minerals, and amino acids within our white blood cells.

Inability to Gain Weight

Some clients want to discuss being underweight and problems with gaining weight. Being underweight can be a risk factor for poor mental health, yet contrary to popular belief there appears to be no association between poor mental health and poor body satisfaction or other body image issues in the non-eating-disordered underweight population. Underweight may result due to poverty, digestive problems, hyperthyroidism, genetics, or drug or alcohol use. A number of problems can underlie inability to gain weight; stimulants and thyroid problems can cause weight loss or prevent weight gain. They include malabsorption associated with gluten or other food allergies, Crohn’s disease, and colitis. Elderly clients may experience sacopenia, which results in muscle loss and is a risk factor for falls and cognitive decline. It generally results from reduced levels of exercise and hormone changes.

Nutritional suggestions for weight gain include high-quality proteins and fats, root vegetables and whole grains, raw nuts, and supplemental smoothies with whey or pea protein added. Weight gain should concentrate on muscle (not fat) gain through amino acid supplementation.

As I have explored earlier, many different symptoms can derive from similar types of imbalances or combinations of complex nutritional deficits. One of the first steps I take following assessment is to provide clients with a handout of a delicious beverage (smoothie) recipe that can be modified according to their specific taste or nutrient needs. Whether they wish to lose or gain weight, decrease depression or anxiety, or improve their energy and cognitive function at any age, this first initial step starts the process of nutritional change (see Appendix F for the Pineapple Coconut Cognitive Smoothie recipe) .

PRACTITIONERS WORKING IN THE FIELD OF NUTRITION

The following practitioners can serve as resources and referrals for collaboration and for prescribing nutritional programs. Following these descriptions, review the table in the appendix that includes the training and credentials for each profession (see Appendix G ). This list may be reviewed with and provided to the client.

Nutritional Counselors/Therapists

These include certified clinical nutritionists, certified nutritional consultants, certified nutritionists, and board-certified physician nutrition specialists (medical professionals with specialized training in nutrition).

Nutritional counselors work with people to assess their nutritional needs and make recommendations for dietary changes to improve health and well-being. A nutritionist has specific nutritional training but is not a registered dietitian.

Registered Dietitians

Registered dieticians (RDs) can help to manage and prevent chronic illness, provide sports nutrition and culinary education, assist with presurgery and postsurgery nutrition, help with eating disorders, lead community efforts to improve food resources, provide guidance with prenatal and perinatal nutrition, and assist with healthy food and nutrition for the elderly. RDs administer medical nutrition therapy in which they review a person’s eating habits, review her or his nutritional health, and create a nutritional treatment plan that is personalized for the individual. Often, though not always, the course of study promotes conventional nutritional guidelines rather than more progressive ones, and thus one should explore the approach taken by the dietician.

Naturopathic Physicians

Naturopathy is a holistic medical system that is guided by the major principle: The Healing Power of Nature (Vis Medicatrix Naturae). It is a blend of natural medicine and allopathic medicine. Naturopathic doctors (NDs) are licensed as primary care physicians in some states in the United States. Naturopathic practice includes the following diagnostic and therapeutic modalities: clinical and laboratory diagnostic testing, nutritional medicine, botanical medicine, physical medicine (including manipulative therapy), counseling, minor surgery, homeopathy, acupuncture, prescription medication, and obstetrics (natural childbirth) .

Functional Medicine Practitioners

Functional medicine uses a systems-oriented and patient-centered approach, addressing the patient as a whole person. Practitioners of functional medicine take extensive patient histories and take time to understand an individual’s unique health needs. They draw from Western and complementary/alternative medicine focusing on science-based prevention and treatments for body, mind, spirit, lifestyle, family, career, and the environment.

Integrative Medical Practitioners

Integrative medicine draws on both allopathic and complementary/alternative medical practices. It is often evidence based and takes into account the patient as a whole person and the relationship between the practitioner and the patient; it uses all available therapies that may help in the treatment of a client.

Health Coaches

A health coach educates and serves as a role model to motivate individuals, couples, families, and communities to explore and enact positive health choices. A variety of health coach training and certification programs exist, and training hours credentials can vary.

Osteopathic Doctors

Osteopathy is a comprehensive medical system that focuses on disease prevention while using the technology of modern medicine to diagnose and treat illness. It is holistic, looking at the patient as a whole person and not just treating isolated symptoms. Osteopathic physicians (DO) are fully trained physicians like MDs; they are able to perform surgery and work with prescription drugs. They also emphasize nutritional therapies and manipulative therapies such as cranial osteopathy.

Traditional Chinese Medicine and Acupuncturists

Traditional Chinese medical practitioners and acupuncturists prescribe individualized diets for the whole person. They take a comprehensive history and conduct a thorough assessment that includes pulse taking, tongue reading, and facial diagnosis. The Chinese nutritional approach is based on having a balance of the five tastes (spicy, sour, bitter, sweet, and salty) and six food groups (meats, dairy, fruit, vegetables, grains, and herbs and spices). Chinese medicine also incorporates the concepts of yin and yang to nutrition and recommends different foods for different times of year .

Traditional Medicine Healers/Practitioners

Traditional medicine involves ways of healing that are passed on from one generation to the next, among families and healers, and is based on indigenous, practical, and observational arts and science. Medicinal plants, animals, foods, the elements, rituals, spirit ways, and touch are all part of the earth’s gifts that make up traditional medicine. Traditional medicine is the property of the communities and nations from which it originates; it emphasizes restoration of balance and prevention of causes and requires the vital preservation of the culture and natural resources of its origin.

Essential Next Steps

After the comprehensive physical and mental health intake, you then may discuss the following with the client:

•  Further testing: discuss timeline, priorities, and costs

•  Elimination diets

•  Additional resources: handouts, reading

•  Allow time for questions and concerns.

•  Discuss a referral or consider a future referral; educate your client about the various clinicians who may be of assistance.

•  Research practitioners working in the field to whom you might refer and collaborate .