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As part of a study of the tryptophan metabolism in mental patients,
a survey was made of the dietary histories and 3-day diet records
of forty-nine patients entering a mental hospital for the first
time. Deficiencies in nutrient intakes were found to be similar
to those of other selected groups in the United States. Although
all patients ingested recommended amounts of tryptophan it is
suggested that the quantity may not be adequate.
Dietary Intakes of Mental Patients
Introduction
in As a part of a study regarding tryptophan metabolism Irene R. Payne, Ph.D. and Mildred M. Hudson
mental patients at a state institution, it was our desire
to assess the dietary histories and patterns of the patients.
As pointed out by Smythies' in his discussion about the he or she: a) was admitted for the first time, so that answers
chemistry, metabolism, and treatment of schizophrenia, one would not reflect "institutionalization"; b) could be inter-
ofthe problems in such experimental investigations has been viewed within twenty-four hours; c) had the ability to com-
the lack of satisfactory correlation of dietary information municate with the person administering the questionnaire;
and physiological measurements. According to Weir and d) was able to eat the regulardiet without modification, unless
Houser,2 this can be explained partially by certain inherent ground meat was necessitated by dental problems; e) was
difficulties in obtaining dietary histories and practices. Two able to walk to a designated dining room.
such difficulties were relevant to our proposed study: a) Ofthe forty-nine patients, nineteen were women and
patients sometimes are unable to give adequate histories; thirty were men, approximately the same proportion as are
and b) the movement of any person from one environment admitted in total and as are patients at any given time.
(such as home) to another (such as an institution) might bring Questionnaires, which had been designed, tested, and
about a change in both metabolism and dietary intake. Our revised in a preliminary period of three months, were all
study was designed to test these suggestions to a certain personally administered by the investigator within twenty-
extent, and to gather dietary information which we felt could four hours of admittance. Food models* for a diabetic diet
be correlated with biochemical measurements, at least as were used as visual aids with the patients.
a pilot study. After completion ofthe questionnaire, the patient was
The means by which we recorded dietary histories assigned to a specific dining room for a sequence of nine
was evolved from a combination of those which Morgan3 meals. Here the patient was served the standard menu served
discussed and which have been successfully used in nutri- at the institution. Standardization included portion sizes. A
tional status studies throughout the U.S.A. dietary aide recorded the patient's name, food served (inclu-
The publication of "Amino Acid Content ofFoods"4 ding any menu changes or additional food eaten), portion
made it possible to calculate the amino acid content of the served if it varied from the Master Menu Manual, and the
recorded food intakes. Since we were studying tryptophan amounteaten(the aide checked the tray as soonas the patient
metabolism, we were interested in assessing the tryptophan finished eating). When the 3-day intake records were com-
intake from the dietary records, using this publication. pleted, the amounts of each food eaten were transferred to
In light of the calculated intakes of niacin and tryp- sheets for calculation ofthe nutrient content. There was con-
tophan amongst this population of mental patients, certain stant and thorough checking against the menus for clarity
aspects of the interrelationships between the two nutrients and accuracy.
and mental health, as discussed in the most recent issue the three
of"Present Knowledge inNutrition,"5 assumed more impor- During days, a 24-hour sample of urine was
tance. Considering all the metabolic products for which tryp- obtained from the patient under the supervision ofthe nurses
tophan is a precursor-i.e., pyridine nucleotides, serotonin, in the ward. These are being analyzed for metabolites of
protein, and probably other compounds-what assurance is tryptophan.
there that serotonin, the known brain constituent, will be tal Atthe time the patient was accepted as an experimen-
synthesized if all the other metabolic pathways do not have subject, a record card was initiated and the patient
enough tryptophan to meet their particular functions? The assigned anumber.Therecordnumberwasusedonallpapers
presence or absence of genetic factors, which involve the andcalculations in orderto conceal the identity ofthe patient.
enzymes that facilitate the pathways, further complicates If any medication was given during the experimental time,
the interrelationship. The continuing part of the study inves- it was noted on the card. At the request of the investigators,
tigates these questions. medication was withheld if at all possible.
For the purpose of checking the reliability of the
Methods and Procedures patient's answers to the original questionnaire, a family
member was administered a questionnaire which contained
Forty-nine patients entering the Anna State Hospital only the same objective questions (not attitudinal). Of the
were included in the study. original twenty-four questions asked both patient and family
patientBetween Sept. 30, 1968 and March 19, 1969, every
entering the hospital was included in the study if *Imitation Food Display Co., 197 Waverly Ave., Brooklyn, N.Y.
1210 AJPH SEPTEMBER, 1972, Vol. 62, No. 9
member, the number which were answered the same by both CANONAwasused in the present study. Correlation coef-
participants were tabulated. From the total tabulations, the ficients given below indicate the extent to which data derived
average per cent of agreement was calculated for the entire from the questionnaire for a given nutrient correlates with
group. It was arbitrarily decided that an agreement of 75 thatforthe same nutrientobtainedby analysis ofdaily intake.
per cent would indicate patients were able to give reliable The other correlation coefficients presented are those
information, as long as it was factual. betweentryptophan, niacin, protein, thiamine, andriboflavin
The data from the questionnaire and the 3-day intake intakes.
records were analyzed for the intake ofcalories, eight essen-
tial nutrients, and tryptophan. Vitamin D was excluded. Results
TheRecommendedDietaryAllowances, revised 1963,
by the Food and Nutrition Board of the National Research Average Intakes of All Patients
Council were used as the basis of calculation of adequacy The calculated quantities of eight nutrients and
of diet. This study was designed and undertaken before the calories from both questionnaires (histories) and the 3-day
later revision was published. Basically the calculations of intake records were averaged. The results, for both men
nutrient values were made using Handbook No. 8, Composi- and women, are shown in Table 1.
tion of Foods6 and Bowes and Church, Food Values ofPor- The averages taken from the questionnaire showed the
tions Commonly Used.7 Additional information for tryp- women did not meet the recommended daily allowances for
tophan estimation was obtained from the Home Economics calories, calcium, iron, vitamin C, and vitamin A, in their
Research Report No. 4, Amino Acid Content of Foods.4 home situations. The same was true during their first three
In several instances letters were written to food companies, days in the hospital, with the exception of vitamin A.
giving the purpose of the study, and requesting analytical Accordingtotheinformationprovidedby menregard-
information of their product being used. In almost every ing their dietary intakes at home, they met all the recom-
case the requested information was received unless they mended daily allowances. However, the records taken in
stated that it was unknown. For food prepared and served the hospitals indicated they did not meet recommended daily
on the hospital menu, it was necessary to calculate the nu- allowances for calories and niacin. The fact that the hospital
trient value of the food from the recipe used. Most of thle menus were planned to provide only 2,100-2,300 calories
recipes used were those in the Master Menu Manual,8 and probablyexplains thefailure ofmentomeetthe2,600calories
all recipes used were checked with the Food Production recommended.
Managerforany substitution orchanges iningredients. Green The overall indication was that female patients did
salad portions served were weighed in three dining rooms not ingest adequate amounts of nutrients based on recom-
and an average portion agreed upon to consist of 42 grams. mended daily allowances, but that male patients did.
Several cuts ofcake were weighed and found to agree closely
with the portion size in Bowes and Church.7 The estimation
of tryptophan for cookies posed a problem as no information Percentage of Patients Not Meeting Recommended Daily
could be secured on these prepared products. Several home Allowances
recipes were calculated and averaged to give an approximate The percentages of patients with an intake below
figure which was used for all cookies. Cereals were evaluated recommended allowances of each nutrient, calculated from
according to the information received from the company pro- questionnaires and 3-day intakes are shown in Figures 1 and
ducing the brand. In recipes using raw foods which were 2.
cookedbefore serving, the food values were adjusted accord- Quite a different pattern in dietary histories emerged
ing to the information given in Procedures for Calculating here. More than 33 per cent of the men ingested suboptimal
Nutritive Values of Home Prepared Foods.9 quantities of calories, calcium, vitamin C and vitamin A.
Although there were afew patients who were younger
and also some older ones, the Recommended Daily Allow-
ances for the reference man and woman in the age bracket Table 1-Average Intake of Nutrients by 19 Men and
from thirty-five to fifty-five were chosen as the standards 30WomenWhoWereNewPatientsata Mental Hospital
for comparison. The per cent of male and female patients
not meeting the RecommendedDaily Allowances forthe eight *Questlonnaire t3-day record
nutrients and calories was calculated and also the per cent Nutrients Men Women Men Women
not meeting two-thirds of the Recommended Daily Allow- Calories 2752 1824 *1995 1504
ances, which Morgan3 stated represented the borderline of Protein (gm.) 123 77 81 61
inadequate choice offoods. This was doneforboth the intakes Calcium (mg.) 1079 727 1035 732
by questionnaire and by 3-day record. The average intake Iron (mg.) 20 12 13 9
of nutrients for the nineteen women patients and the thirty Thiamine (mcg.) 1967 1301 1200 909
men was also figured and compared with the Recommended Riboflavin (mcg.) 2440 1513 2113 1478
Daily Allowance for both the questionnaire and the 3-day Niacin (mg.) (preformed) 25 17 16 13
record. Vitamin C (mg.) 70 57 72 56
for Inter-test consistency was evaluated, using a program Vitamin A (I. U.) 6247 3549 7601 5188
canonical correlation analysis, a generalized statistical Tryptophan (mg.) 1405 926 978 727
model which enables the researcher to determine all indepen-
dent correlations between two sets ofvariables. The method *Dietary histories
was developed by Hotelling,10 and computer programs are tActual intake during first three days in hospital
available in Cooley and Lohnes'I and Veldman.12 Veldman's tCaloric content was controlled
DIETARY INTAKES OF MENTAL PATIENTS 1211
Figure 1-Percentage of Patients With an Intake Below Figure 2-Percentage of Patients With an Intake Below
the Recommended DailyAllowances(Taken FromQues- the Recommended DailyAllowances (taken From 3-Day
tionnaire) Records of Hospital Diet)
Percent Percent
S a a a ft l a lt a a
I I 1 H11 1 1CL RI I I I I I I I I I I I
CALOR ES CALORIES
- ~~NWMM%
PROTEIN PROTEIN
0 - _~Mu
CALCIUM CALCIUM
I RON I RON
THIAMINE 'THIAMINE
RIBOFLAVIN RIBOFLAVIN
NIACIN
V17AMIUN C VITAMIN C
_l-lli-
_~~~~--
_ VITAMIN A
_ ยง VITAMIN A
-~~~~~~~~~111 _UX>I
MEN WOMEN MEN WOMEN
The diets of more than 33 per cent of the women were tities of calcium, iron, riboflavin, vitamin C and vitamin A.
deficient in calories, calcium, iron, riboflavin, vitamin C, Thirty-two per cent of the men failed to meet two-thirds
and vitamin A. Obviously, quantities of nutrient intakes in of the recommended daily allowance in vitamin C only.
excess of recommended daily allowances reported by the Whenthesamecomparisonsweremadeunderhospital
other participants had offset and masked intakes ofthe group conditions, more than 32 per cent of the women failed to
as a whole, as shown in the previous section. eat two-thirds of recommended daily allowances ofcalories,
The incidence offailure to meet recommended allow- calcium, iron, niacin, vitamin C and vitamin A. The percen-
ances by women when they were in the hospital was higher tage of men failing to eat two-thirds of the recommended
than that shown by questionnaire. Thirty-three per cent or daily allowances of any nutrient was less than 32 per cent.
more women had suboptimal levels of all the nutrients The indication was that about one-third ofthe women
studied. Thirty-three per cent or more of the men were not only did not meet recommended daily allowances ofcal-
deficient in calories, niacin, vitamin C and vitamin A. The cium, iron, riboflavin, vitamin C and vitamin A, but they
percentage ofboth men and women failing to receive recom- did not ingest even two-thirds of the recommended amounts
mended daily allowances ofnmacin was greater in the reports of these nutrients. On the other hand, the 33 per cent of
from the hospital than in those from the questionnaires. the men who did not meet the total daily requirements of
calcium, vitamin C and vitamin A, did at least ingest two-
Percentage of Patients Not Meeting Two-Thirds of thirds of the RDA for these nutrients.
Recommended Daily Allowances Reliability of Patients' Reports of Dietary Histories
did notFigures 3 and 4 represent percentages ofpatients who
of meettwo-thirds ofthe daily recommended allowances The number and percentage of objective questions
each nutrient. to than 32 on the questionnaire which were answered the same by both
ofthe According questionnaires, more per cent a patient and a family member were recorded. 31 family
womenfailed to obtain two-thirds ofthe desired quan- contacts were made, or 63 per cent of the questionnaires
1212 AJPH SEPTEMBER, 1972, Vol. 62, No. 9
Figure 3-Percentage of Patients With an Intake Below Figure 4-Percentage of Patients With an Intake Below
Two-Thirds of Recommended Daily Allowances (Taken Two-Thirds of Recommended Daily Allowances (Taken
From Questionnaire) From 3-Day Records of Hospital Diet)
R!rcent Percent
a as 2 ae n m
I I I I I I I I I I I I I I I I I I I I I I I
CALORIES CALORIES
_ Wm
PROTEIN PROTEIN
I
CALCIUM CALCIUM
Em
IRON IRON
_------- g _----0-
THIAMINt- THIAMINE
I
RIBOFLAVIN RIBOFLAVIN
NIACIN NIACIN
VITAMIN C VITAMIN C
IUM
VITAMIN A VITAMIN A
~ wa
MEN WOMEN MEN WOMEN
were verified this way. There was agreement between the As was expected, very strong correlations of niacin
patients and family members in answer to an average of and tryptophan with the three other nutrients which are
76 per cent of the questions, which would appear to show implicated in mental disorders were found, the indication
that in this survey the information given by the patients could being that a deficiency in either tryptophan or niacin was
be considered quite reliable. concomitant with deficiencies in protein, thiamine, and ribo-
flavin. The correlation factors are presented in Table 2.
Correlations Between Dietary Histories and 3-Day Hospi- These results, of course, reflect food composition,
tal Records but they serve to give a measured relationship.
The statistical study of quantities of each of the nu- Discussion
trients from the questionaires with the quantities ofthe same
nutrients shown in the 3-day records indicated very little As has often been stressed by those investigating the
if any, agreement between the two means ofgaining dietary nutritional status of populations, the conclusions that can
information. The highest correlation values were or should be drawn from average intakes of nutrients are
.38, +-.34, and +-.39 for thiamine, protein, and tryptophan not manyorveryrevealing. Forthat reason we have included
respectively. a minimum presentation of the averages. Even though the
calculation of the percentages of patients who did not meet
Correlation Between Niacin, Tryptophan, Protein, recommended daily intakes, or two-thirds thereof, did not
Thiamine, and Riboflavin Intakes give as complete a picture of the nutritional health of these
patients as was desirable, it did give us information which
Both the questionnaires and the 3-day hospital records could be compared with similar data gathered throughout
revealed a strong positive correlation between the quantities the United States and compiled by Morgan.3 This same basic
of niacin and tryptophan, the former giving a correlation data will give us even more insight into individual nutritional
factor of +.79 and the latter a factor of +-.86. health and metabolism when some of it is correlated with
DIETARY INTAKES OF MENTAL PATIENTS 1213
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