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Medical Foods

Psychopharmacology 101

For Non-prescribing

Mental Health Professionals -

A Training Resource

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T

Medical Foods

The Food-Drug Spectrum - Created Mid-80’


Medical Foods “Nutrient Pharmacology” for the following conditions

  • PKU - Phenylketonuria
  • Metabolic Syndrome
  • Osteoporosis
  • Chronic Pain
  • Gastrointestinal
  • Neuropsychology

 

Medical Foods: Therapeutic Areas

PKU – Phenylketonuria - decreases plenylalanine protein formulas; increases amounts of large

neutral amino acids (e.g., tyrosine, tryptophan)

Metabolic Syndrome – B-vitamins, soy fiber, plant sterols, EPA/DHA (eicosapentaenoic & docosahexaenoic acids)

Osteoporosis – Vitamin D, zinc, genestein, calcium

Chronic Pain - Choline, tryptophan, arginine, glutamine, histidine; GABA, antioxidants (gingko biloba, grape seed extract, and cinnamon)

Gastrointestinal – Soluble fibers, probiotics, vitamins, minerals, amino acids, and/or hydrolyzed protein; ginger, rosemary, turmeric; MCTs, Medium Chain Triglycerides

Neuropsychology – MCTs (Medium Chain Triglycerides), B-12, folic acid (L-methylfolate), DHA/EPA, Vitamin C, Vitamin E

 

Medical Foods Benefits

  • Not used as Monotherapy
  • Reduction in medication side effects (as a result of combo therapy)
  • May lower drug/medical costs
  • Enhances drug adherence
  • Encourages patients to take active role in overall nutrition
  • Perceived as more Natural than Drugs
  • Insurance Programs Pay
  • Governing Authority: Orphan Drug Act 1983 - Act to amend the Federal Food, Drug, & Cosmetic Act to facilitate development of drugs for rare diseases and conditions. Act to amend the Federal Food, Drug, & Cosmetic Act to facilitate development of drugs for rare diseases and conditions. Scientific Scrutiny: Per Medical Evaluation Act to amend the Federal Food, Drug, & Cosmetic Act to facilitate development of drugs for rare diseases and conditions.
  • Scientific Scrutiny: Per Medical Evaluation
  • Composition/Ingredients: Nutritional/Missing from Diet
  • Claims: Dietary Mgt of Specific Disease
  • Safety: “Generally Regarded as Safe” (GRAS)
  • Supervision: Required

L-methylfolate (Deplin®/Enlyte®) (Medical Food)

FDA Approved for:Suboptimal folate levels in depressed patients (adjunct to antidepressant) & Hyperhomocysteinemia in schizophrenia patients (adjunct to antipsychotic)

Doses: 15 mg to 30 mg per day

Aspect of B vitamin that crosses blood brain-barrier (BBB)

Why not vitamin B6 (Pyridoxine) or B9 (Folic acid)?

L-methylfolate ; Regulator of homocysteine; increases plasma homocysteine; risk factor in development of Alzheimers (ALZ); L-methylfolate decreqwew homocysteine levels especially in patients with decreased plasma folate

Note: ALZ patients may suffer from decreases plasma folate and l-methylfolate levels

 

Juven® (Medical Food)

Indications: Supports tissue building; Diseases that cause weight loss, cachexia, and age related muscle loss (sarcopenia)

Ingredients: HMB (hydroxymethylbutyrate), L-leuine, L-glutamine

Mechanism of Action: Inhibition of protein breakdown & stimulation of mTOR (mammalian target of rapamycin) pathway

 

App Trim® (Medical Food)

Indications: Obesity; Insulin resistance & forms of metabolic dysfunction

Ingredients: Whey protein, amino acids, Griffonia seed extract, cocoa, caffeine

Mechanism of Action: Increase amino acids involved in appetite regulation increase lipolysis

 

Sentra PM® (Medical Food)

Indications: Depression related sleep disorders

Ingredients: NT precursors, polyphenols

Mechanism of Action: Neurotransmitters involved in sleep regulation

 

GABAdone® (Medical Food)

Indications: Management of metabolic processes associated with sleep disorders

Ingredients: Choline bitartrate, GABA, cocoa extract, l-glutamine, whey protein isolate, Griffonia extract, valerian root, acetyl l-carnitine, ginko biloba, grape seed extract

Mechanism of Action: Supports NT that regulate sleep: serotonin, GABA, Ach – More research needed

 

Trepadone® (Medical Food)

Indications: Pain, inflammation syndromes, arthritis

Ingredients: Whey protein, GABA, L-histidine, glucosamine/chondroitin, omega-3-fatty acids,

polyphenols

Mechanism of Action: Supports synthesis of NTs involved in managing joint disease

 

Theramine®(Medical Food)

Indications: Management of metabolic processes associated with pain/inflammatory conditions & chronic pain

Ingredients: GABA, choline, whey protein, arginine, histidine, glutamine, theobromine, Griffonia seed, grape seed, serine, cinnamon

Mechanism of Action: Stimulates GABA, serotonin, & norepinephrine

 

Pulmona® (Medical Food)

Indications:Management of metabolic processes associated with pulmonary hypertension & bronchospasm

Ingredients: L-arginine, l-glutamine, l-histidine, l-leucine, lcysteine, choline bitartrate, whey protein hydrolysate, cinnamon, ginkgo biloba, grape seed extract, caffeine, cocoa extract

Mechanism of Action: Improves endothelial function, lowers hypertension via production of nitric oxide

 

Vascazen® (Medical Food)

Indications:Cardiovascular disease; dietary Management of omega-3 deficiency

Ingredients: EPA and DHA in patented 6:1 ratio

Mechanism of Action: Inhibition of pro-inflammatory eicosanoids; Increased production of anti-inflammatory eicosanoids & Down regulation of NFKB, major inflammatory pathway

 

Limbrel® (Medical Food)

Indications: Osteoarthritis

Ingredients: Polyphenol flavonoids

Mechanism of Action: COX-2 (pro-inflammatory) inhibitors and 5-LOX (lipoxygenase) pathways

 

Axona® (Medical Food)

Indications: Alzheimer’s Disease

Ingredients: Caprylic Acid, Medium Chain Triglyceride

Mechanism of Action: Inhibition of protein breakdown & stimulation of mTOR (mammalian target of rapamycin) pathway

 

Cerefolin NAC® (Medical Food)

Indications: Cognitive Impairment

Ingredients:  B12, , L-methylfolate, NAC (N-Acetyl cysteine)

Mechanism of Action: Regulator of homocysteine levels & MTHFR (methylene-tetra-hydrofolate reductase, involved in folate production) polymorphism

 

Vayarin® Lipirinen™ ADHD (Medical Food)

Omega-3-Long Chain Polyunsaturated Fatty Acids

No sugar, lactose, yeast, or gluten

Avoid with Anti- & Cholinergic Meds

Avoid with shellfish allergies

Composed of 167 mg of Lipirinen™:Phosphatidylserine (PS); Eicosapentaenoic Acid (EPA) & Docosahexaenoic Acid (DHA)

 

National Nutrient Database

http://ndb.nal.usda.gov/

Comprehensive Data Base (8000 Foods)

Foods sorted by specific nutrients (e.g., omega-3, magnesium, folate)

Includes Restaurant Foods

Eating Disorders

Genetics, Neurobiological, Societal Influences, Psychological Factors

Treatment Difficulty Level: High - 6% Die from Complications: Cardiac Arrest & Electrolyte Imbalance

Anorexia - Highest Death Rate

“Orexia” - L. “longing, appetite.”

Goal of Therapy: Proper Eating Behavior and Weight Gain

 

Eating Disorders


Anorexia Nervosa

Long History, Nothing New

Refusal to maintain normal body weight

Pursuit of thinness

Distorted body image

Compensatory strategies

Excessive exercise

Ingesting laxatives & diuretics

Genetics – 5-HT2A gene, consistent positive findings

Role in obsessive compulsive personality, perfectionism, inflexibility

Perfectionism: Striatum abnormal activation

Decreased Gray Matter & White Matter

Atrophy of Cerebellar Gray Matter

Cingulate Damage, “Brain’s Gear Shift” is stuck

Signs are promising brain can be restored

 

Anorexia Nervosa Treatments

No medication that will alleviate behavioral and cognitive mis-conceptions

50% of patients still prescribed a medication

Antidepressant & Antipsychotics: No evidence of success or failure in successful treatment of core symptoms

Caution: Prozac®/Fluoxetine/anorexigenic is anorexigenic decreases appetite

5-HT3A: Anorexigenic/appetite suppressant

Behavioral Treatments for Weight Gain

 

“Stacker Diet Pills”

Usually contain ephedra which mimics adrenalin in humans

“ECA Stack” Ephedrine stimulant (suppress appetite); Caffeine stimulant & Aspirin

 

Bulimia Nervosa (1979)

Latin. “bolismos,” ravenous hunger” Greek “bous,” ox; + “limos,” hunger

Three Main Criteria: Pre-occupation with Weight; Recurrent Binge Eating; Recurrent Compensatory Behavior

32% - 3.9% Mortality Rate (5% Anorexia)

Neuroimaging: higher Striatal Volume (Perfectionism) & Limitations in synaptic pruning associated with dysfunction in food-reward processing

Purging - Russell’s Sign - when calluses develop on three fingers which are used to force purging

 

Bulimia Nervosa Treatment

Prozac®/fluoxetine: Remember: Unique Action appetite suppressant; May be appropriate if patient also experiencing depression; No reliable evidence between patient characteristics

and eventual response to medication & No response to meds in 3 weeks, not likely to respond

Interpersonal & CBT better than behavioral treatment without cognitive component

 

Binge Eating Disorder (New to DSM-5)

Rapid & excessive food consumption that is not due to metabolic need or hunger

Occurs in discrete episodes that result in an uncomfortable full feeling at least 2X a week

Real Diagnosis? 5% of US Population at least point in life

Psychological Symptoms: Depression/anxiety/addictive behavior & Feelings of Distress & Loss of control

Binge Eating Disorder (BED)

Neurochemistry and BED: Consistent with those diagnosed with substance abuse behaviors; Dopamine and endogenous opiods implicated

Neuroimaging: Limited Studies -BED & BN greater cerebral volume in the medial orbitofrontal cortex compared to controls (associated with dysfunction in food-reward processing/self regulation)

 

Binge Eating Disorder Treatment

Vyvanse®/lisdexamfetamine (Approved 2/15) (takes away the desire to eat); MOA: Prodrug Amphetamine: Sympathomimetic, lowers Desire to eat. Question: Does it treat core problem?

Treatment: Weight Loss;  Cognitive Behavioral Therapy-Enhanced (CBT-E) – Three Modules: Interpersonal Psychotherapy; Coping strategies for “Mood Intolerance” & Body Shape

 

Orthorexia

An obsession with eating foods that one considers healthy

n. orthorexia nervosa

Nutrition & Mental Health

Monoaminergic Rich Foods

Anticholinergic Rich Foods

Inflammation

Nutrition & Mental Health

Precursors

MONOAMINES

CATECHOLAMINES

INDOLAMINES

“CATS LIVE IN THE DEN”

Dopamine

Epinephrine

Norepinephrine

5-HT; Serotonin

Histamine

Melatonin

 

 

MONOAMINES

CATECHOLAMINES

INDOLAMINES

“CATS LIVE IN THE DEN”

Dopamine

Epinephrine

Norepinephrine

Tyrosine

Tyramine

5-HT; Serotonin

Histamine

Melatonin

 

 

Serotonin Precursor

Carbohydrates

Cause a release of insulin and an uptake of large-chair amino acids into peripheral

tissue

Easier for tryptophan to get to brain

Increases serotonin by 18%

Do not mix carbohydrates & protein for this effect

 

Multi-Step Pathway of Serotonin Synthesis

L-Tryptophan

Tryptophan hydroxylase

L-5-Hydroxytryptophan (5-HTP)

Aromatic L-amino acid decarboxylase

5-Hydroxytryptamine (5-HT; serotonin)

 

The Role of Protein in Mental Health

Protein impoverished diet = lower Tyrosine

Lower Tyrosine = Lower DA Lower NE Lower Epi

 

Multi-Step Pathway of Catecholamine Synthesis

Tyrosine

Tyrosine hydroxylase (TH)

DOPA

DOPA decarboxylase (Aromatic amino acid decarboxylase)

Dopamine

Dopamine B-hydroxylase

Norepinephrine

Phenylethanolamine-n-methyltransferase (PNMT) Epinephrine

Acetylcholine : “Non-amine-amine” Precursor: Choline

Brain Foods

DOPAMINE

Chocolate

Wheat

Milk

Fish

Chicken & Eggs

Beans

Nuts

*Iron

Vitamin B2 & B6 (Both DA and 5-HT)

SEROTONIN

Poultry

Fish

Pumpkin Seeds problems prostrate & bladder

Chickpeas

Nuts

Bananas

High Carbs: Pastas, breads, rice

Vitamin B2 and B3 – convert tyrosine and tryptophan into 5-HT

IRON (Mineral)

Chicken/Beef Liver

Claim/Mollusks/Oysters

Beef

Chicken

Turkey

Lentils

Beans

Spinach

ACETYLCHOLINE Memory, Movement

Beef Liver

Beef

Scallops

Chicken Breast

Cod

Shrimp

Brussel Sprouts/Broccoli

Peanut Butter

Milk Chocolate

 

Mental Health Vitamins

B2 - Riboflavin

B3 - Niacin

B6 - Pyridoxine

5-HT Precursor: Convert

Tyrosine & Tryptophan

into 5-HT(serotonin)

Foods:

Spinach

Brussel Sprouts

Broccoli

Eggs

Yogurt

Milk

Liver

Almonds

5-HT Precursor: Convert

Tyrosine & Tryptophan

into 5-HT(serotonin)

Foods:

Beets

Fish

Salmon

Swordfish

Tuna

Sunflower Seeds

Peanuts

Precursor for Serotonin

& Dopamine

Foods:

Spinach

Celery

Fish

Poultry

Lean Beef

Cauliflower

Banana

 

 

Mini-Nutrition Summary

• Chicken & Eggs contribute to synthesis of all 4 Neurotransmitters

• Beef, Turkey, Bananas, & Chocolate contribute to 3 of the 4 Neurotransmitters

 

Inflammation - ½ billion years old

 

Causes of Inflammation

Overweight

Poor Diet, Rich in Inflammatory Foods

Increased Anxiety

Increased Stress & Cortisol Secretions

Heart Condition

Family History of Heart Conditions

Sedentary Life Styles

No Exercise

Smoking

Long Term Infection

Gum Disease

 

Inflammatory Foods

Sugar

Soda

Alcohol

Bread

Red Meat

Bacon

Lard

Salad Dressings

Processed Foods

Transfats: Snack foods; Fried Foods; Crackers; Baked Goods & Vegetable Shortenings

 

ANTI-Inflammatory Foods

Fruits

Vegetables

Mediterranean Diet

Olive Oil

Decrease Inflammation & Inhibits cyclooxygenase

Test:

D-reactive protein CRP (C-ReactiveProtein) Blood test: 

  • < 1 mg per liter of blood = low
  • 1.0 – 2.9 = moderate risk
  • >3 = High Risk