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Nutrition Interventions in Addiction Recovery: The Role of the Dietitian in Substance Abuse Treatment 2013

Are you curious about the connection between nutrition and drug addiction? David A. Wiss, MS, RDN, CPT reviews the literature, makes recommendations for medical nutrition therapy, and shares some suggestions to run groups in treatment facilities.

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Nutrition Interventions in Addiction Recovery: The Role of the Dietitian in Substance Abuse Treatment 2013

  1. 1. Nutrition Interventions in Addiction Recovery: The Role of the Dietitian in Substance Abuse Treatment
  2. 2. WEBINAR OBJECTIVES • Discuss the impact of addictive substances on nutritional status and links to chronic disease • Explore disordered and dysfunctional eating patterns in addicted populations • Evaluate the impact of nutrition interventions in substance abuse recovery • Propose nutrition therapy guidelines for specific substances and for poly-substance abuse
  3. 3. WHAT IS BEHAVIORAL HEALTH NUTRITION (BHN)? • Dietetic Practice Group (DPG) of the Academy of Nutrition and Dietetics (www.bhndpg.org) • RDs/RDNs specializing in: • Addictions • Eating Disorders • Intellectual/Developmental Disabilities • Mental Health • Our vision is to optimize the physical and cognitive health of those we serve through nutrition education and “Fuel Your Brain, Feel Your Best” behavioral health counseling
  4. 4. BACKGROUND – PROBLEM 2011 Data1 • Nearly 25% persons > 12 years binge drank (≥5 drinks one occasion) w/in 30 days • Heavy drinking (≥5 binge episodes in 30 days) reported by 6.2% persons > 12 yrs • 9% persons aged 12+ illicit drug use • Age 50-59 illicit drug use • 2.7% in 2002 dramatically 6.3% in 2011 • 8% of population aged 12+ meet DSM-IV criteria for substance abuse or dependence • 40% concurrent alcohol-drug combinations2 1. Substance Abuse and Mental Health Services Administration. (2012). Results from the 2011 national survey on drug use and health: Summary of national findings (NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Retrieved from http://www.samhsa.gov/data/nsduh/2k11results/ nsduhresults2011.htm 2. Substance Abuse and Mental Health Services Administration (2011). Treatment episode data set (TEDS) 1999 – 2009: National admissions to substance abuse treatment services (DASIS Series: S-56, HHS Publication No. (SMA) 11-4646). Retrieved from http://wwwdasis.samhsa.gov/teds09/teds2k9nwe
  5. 5. WELCOME TO THE WELLNESS MOVEMENT! Through its Wellness Initiative, the Substance Abuse and Mental Health Services Administration (SAMHSA) pledges to promote wellness for people with mental health and substance use challenges by motivating individuals, organizations, and communities to take action and work toward improved quality of life, cardiovascular health, and decreased early mortality rates. www.samhsa.gov/wellness
  6. 6. WHY IS WELLNESS VITAL TO MENTAL HEALTH RECOVERY? • Behavioral health disorders and chronic illnesses are linked • Increased morbidity/mortality largely due to treatable medical conditions caused by preventable risk factors: • Smoking • Obesity • Substance use • Inadequate access to medical care1 • Wellness impacts physical health and recovery process Must take care of body to maintain good physical health and stay on the path to recovery 1. National Association of State Mental Health Program Directors (2008). Measurement of health status for people with serious mental illness. Retrieved from http://www.nasmhpd.org/docs/publicatio ns/MDCdocs/NASMHPD%20Medical%20Di rectors%20Health%20Indicators%20Report %2011-19-08.pdf
  7. 7. SAMHSA’S VISION FOR WELLNESS SAMHSA envisions a future in which people with mental health and substance use challenges pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources.
  9. 9. THE PHYSICAL DIMENSION PHYSICAL — recognizing the need for physical activity, healthy foods, sleep • Staying active: taking stairs, walking instead of driving • Making healthful food choices • Getting enough sleep. This is as important as diet and exercise • See your primary care doctor regularly • See a Registered Dietitian Nutritionist • Background in Behavioral Health
  10. 10. A Manual for Alcoholics Anonymous Written and Distributed in 1940 By Dr. Bob’s Home Group, AA Group No. 1, Akron Ohio “We find that it is wise to eat balanced meals at regular hours, and get the proper amount of sleep without the unhealthy aid of liquor and sleeping pills… The reason for this advice is simple. If we are undernourished and lack rest we become irritable and nervous. In this condition our tempers get out of control, our feelings are easily wounded and we get back to the old and dangerous thought processes.”
  11. 11. Verzar, F. (1955). Nutrition as a factor against addiction. The American Journal of Clinical Nutrition, 3(5), 363-374. “The dangerous effects of starvation in contributing to personality deterioration, together with the additional dangers of addiction, might be abolished, and a problem that is mainly psychological might thus be solved by better nutrition” • Chewing coca leaves (South America), association between cocaine and inhibition of hunger • Improvements in nutrition of cocaaddicted populations may abolish addictive habit of coca chewing
  12. 12. ACADEMY OF NUTRITION AND DIETETICS • Formerly the American Dietetic Association (ADA) • Position paper (1990) supporting need for nutrition intervention in treatment/recovery from addiction • Registered Dietitians (RDs) essential members of the treatment team • Nutrition care integrated into the protocol rather than “patched on” • Nutrition professionals urged to “take aggressive action to ensure involvement in treatment and recovery programs.” American Dietetic Association (1990, September). Position of the American Dietetic Association: Nutrition intervention in treatment and recovery from chemical dependency. Journal of the American Dietetic Association, 90(9), 1274-1277.
  13. 13. SO WHAT HAPPENED? Little progress incorporating dietitians into drug rehabilitation programs despite continued explosion of drug abuse • Lack of interest from RDs • Difficulties conducting research on this population • Non-collaboration between public and private sector • Limited funding for new initiatives • Associated stigmas of drug abuse
  14. 14. NUTRITION AND SUBSTANCE ABUSE • Primary Malnutrition • Displaced, reduced, compromised food intake • Secondary Malnutrition • Alterations in: • • • • Absorption Metabolism Utilization Excretion • Due to compromised health: • • • • • Oral Gastrointestinal Circulatory Metabolic Neurological Immune system Inadequate response to disease
  15. 15. DRUG ADDICTION VS. ALCOHOL • Negative effect of alcohol on nutritional status well-described • Protocols in place (i.e. thiamine) • Illicit drug-induced malnourishment largely unknown • Primary or secondary? • Poly-drug abuse • Ethical/legal challenges with controlled trial research • Poor patient follow-up Most data speculative, underpowered, retrospective
  16. 16. DRUG ABUSE IS A RISK FACTOR FOR: • Metabolic Syndrome1 • Cluster of CVD risk factors: abdominal obesity, diabetes/pre-diabetes, elevated cholesterol, high BP • Eating Disorders2,3,4 • ED in male population underdiagnosed, undertreated, misunderstood by clinicians5 • Altered responses to sugar, salt, fat6,7 1. Virmani, A., Binienda, Z. W., Ali, S. F., & Gaetani, F. (2007). Metabolic syndrome in drug abuse. Annals of the New York Academy of Science, 1122, 50-68. doi:10.1196/annals.1403.004 2. Krahn, D. D. (1991). The relationship of eating disorders and substance abuse. Journal of Substance Abuse, 3(2), 239-253. 3. Wilson, G. T. (2010). Eating disorders, obesity, and addiction. European Eating Disorders Review, 18, 341351. doi:10.1002/erv.1048 4. Fischer, S., Anderson, K. G., & Smith, G. T. (2004). Coping with distress by eating or drinking: Role of trait urgency and expectancies. Psychology of Addictive Behaviors, 18(3), 269-274. doi:10.1037/0893-164X.18.3.269 5. Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating disorders in men: Underdiagnosed, undertreated, and misunderstood. Eating Disorders: The Journal of Treatment & Prevention, 20(5), 346-355. doi:10.1080/10640266.2012.715512 6. Gant, C., & Lewis, G., (2010). End your addiction now. Garden City Park, NY: Square One Publishers. 7. Levine, A. S., Kotz, C. M., & Gosnell, B. A. (2003). Sugar and fats: The neurobiology of preference [Special section]. Journal of Nutrition, 831S-834S.
  17. 17. CO-OCCURING SUBSTANCE USE DISORDER (SUD) & EATING DISORDER (ED) • HOT TOPIC (shortage of data!) • Anorexia nervosa (AN) + AUD • Alcohol use disorder (AUD) + AN • Bulimia nervosa (BN) + AUD • AUD + BN • BN + SUD • SUD + BN • Binge eating disorder (BED) + SUD • SUD + BED (often sub-threshold)
  18. 18. AUD/SUD – NEWLY SOBER • Altered biochemistry remains • Dysfunctional behavior surfaces and persists • Making healthful food choices after abstinence achieved may be very challenging • Sobriety: new emotions, anxiety, uncertainty • Easy to seek a predictable and comforting response from food Overeating, relapse, compromised quality of life, chronic disease
  19. 19. STILL SOBER… • Increased caloric consumption, excessive intake of sugar/salt/fat often lead to: • Obesity: linked with SUD in men1 • Diabetes • Hypertension 1. Barry, D., & Petry, N. M. (2009). Associations CVD between body mass index and substance use Clinical burden associated with substance national epidemiological survey on alcohol and related conditions. Addictive Behavior, (34)1, 51- abuse $$$$$$$$$$$$$$$ 60. doi:10.1016/j.addbeh.2008.08.008 Even a remote history of SUD can negatively impact weight disorders differ by gender: Results from the loss2 2. Robinson, C., & McCreary, C. (2011, July). The relationship between a history of substance use disorders and weight loss success: A program evaluation of WLA MOVE! level 2.
  20. 20. DIABETES (DM) • AUD, SUD, ED all associated with abnormal glucose metabolism1 • When BG drops: depression, anxiety, moodiness, craving for usual drug, behavior, or food1 • Sugar sensitivity and abnormal glucose metabolism in alcoholics and addicts2 (direct correlations to DM unknown) • Blunted responses in insulin, glucagon, BG in 20 long-term abstinent alcoholics (6+ months) following controlled administration of glucose3 1. Althaus, C. B. (2001). The glucose factor: Diet and addiction. Foodservice Director, 14(10), 62. 2. Hatcher, A. S. (2008). Nutrition and addictions. Dallas, TX: Understanding Nutrition, PC. 3. Umhau, J. C., Petrulis, S. G., Diaz, R., Riggs, P. A., Biddison, J. R., & George, D. T. (2002). Long-term abstinent alcoholics have a blunted blood glucose response to 2-deoxy-D-glucose. Alcohol and Alcoholism, 37(6), 586-590.
  21. 21. HYPERTENSION (HTN) • High levels of sodium intake elevate blood pressure and contribute to HTN • Strokes and CVD1 • Increased risk of kidney disease1 • Alcoholics sober for 6-12 months experienced abnormal responses in blood 1. Yalamanchili, V., Struble, J., Novorska, L. A., & Reilly, R. F. (2011, October). Dietary pressure and plasma rennin activity when exposed to variations in salt intake2 Physiological characteristics of individuals with a history of substance abuse may contribute to the development of nutrition-related chronic disease sodium restriction in veterans: a modifiable risk factor for chronic disease. Federal Practioner, 39-42. 2. Gennaro, C. D., Barilli, A., Giuffredi, C., Gatti, C., Montanari, A., & Vescovi, P. P. (2000). Sodium sensitivity of blood pressure in long-term detoxified alcoholics. Hypertension, 35, 869-874.
  22. 22. WHAT WE KNOW FOR SURE… • Evidence to date indicates individuals in recovery may benefit from learning new behaviors with respect to food & nutrition • Increasing body of evidence that suggests 1. Barbadoro, P., Ponzio, E., Pertosa, M. E., Aliotta, F., D’Errico, M. M., Prospero, E., & Minelli, A. (2011). The effects of educational intervention on nutritional behaviour in alcohol-dependent patients. Alcohol and Alcoholism, 46(1), 77-79. doi:10.1093/alcalc/agq075 nutrition interventions in substance abuse 2. Grant, L. P., Haughton, B., & Sachan, D. S. treatment lead to improved outcomes1,2,3 associated with substance abuse treatment (2004). Nutrition education is positively program outcomes. Journal of the American Dietetic Association, 104(4), 604-610. 3. Cowan, J. A., & Devine, C. M. (2012). Dysfunctional eating patterns and nutritional interventions in the SUD population both require further investigation Process evaluation of an environmental and educational intervention in residential drugtreatment facilities. Public Health Nutrition, 15, 1159-1167. doi:10.1017/S1368980012000572
  23. 23. ADDICTION & MENTAL HEALTH • Addictive substances strip brain of essential fats, and impair absorption/utilization of AA’s necessary for 1. Grotzkyj-Giorgi, M. (2009). Nutrition and addiction – can dietary changes assist with recovery?. Drugs and Alcohol Today, 9(2), 24-28. neurotransmitter synthesis1 2. Buydens-Branchey, L., & Branchey, M. (2006). N-3 polyunsaturated fatty acids • Controlled studies have linked essential fatty acid deficiency to anxiety as well as population of substance abusers. relapse2,3 Journal of Clinical Psychopharmacology, • ***Nutrient deficiencies/imbalances may cause behavior resembling dual diagnosis decrease anxiety feelings in a clinical diagnoses should be postponed until nutritional issues have been addressed*** • “Better collaboration among treatment professionals is needed in order to serve the multifaceted needs of 26(6). doi:10.1097/01.jcp.0000246214.49271. fl 3. Buydens-Branchey, L., Branchey, M., McMakin, D. L., & Hibbeln, J. R. (2003). Polyunsaturated fatty acid status and relapse vulnerability in cocaine addicts. Psychiatry Research, 120, 29-35. doi:10.1016/S0165-1781(03)00168-9 4. Kaiser, S. K., Prednergast, K., & Ruter, chemical dependent patients, and reduce prescriptive care contraindicated in the condition of substance abuse.”4 T. J. (2008). Nutritional links to substance abuse recovery. Journal of Addictions Nursing, 19, 125-129.
  24. 24. NUTRITION & MENTAL HEALTH 1. What are neurotransmitters? 2. Where do they come from? 3. Psychotropic medication & neurotransmitters? 1. Cell membranes composition? 2. Where does this come from?
  25. 25. NUTRITION & MENTAL HEALTH • Essential nutrients profoundly impact cells & brain chemistry • Wernicke-Korsakoff Syndrome (thiamine deficiency in AUD pts) • Thiamine deficiency: • Poor appetite, weakness, irritability, depression
  26. 26. NUTRITION & MENTAL HEALTH • Other nutrient deficiencies: • Vitamin B6 • Depression, psychological issues • Folate (folic acid) • Depression, apathy, fatigue, poor sleep, poor concentration • Vitamin B12 • Changed mental status, depression • Iron • Symptoms of poor mood, attention Behavioral Health Nutrition Dietetic Practice Group (2006). Psychiatric nutrition therapy: A resource guide for dietetics professionals practicing in behavioral healthcare. Available from https://www.bhndpg.org/store/item_view. asp?estore_itemid=1000008
  27. 27. NUTRITION & MENTAL HEALTH • Nutrient deficiencies: vitamin D • Depression, mood disorders • Will taking large amounts of vitamin supplements fix this? • Is severe malnourishment in US likely? • Possible?
  28. 28. FOOD & MOOD – Carbohydrates • High carbohydrate (CHO) intake Hyperglycemia Hyperinsulinemia Hypoglycemia (reactive) • “Crash” • Confusion, visual disturbances, abnormal heartbeat, shakiness, anxiety/nervousness, sweating, tired/weak, hunger, relapse
  29. 29. FOOD & MOOD – Carbohydrates • Is a low-carb diet the answer? NO • Need minimum of 100-150 g CHO/day • Glucose brain, CNS function • Carbohydrate ingestion: • Insulin promotes the cellular uptake of glucose & amino acids (AA) (except for tryptophan) • Tryptophan brain Leyse-Wallace, R. (2008). Linking nutrition to mental health. Lincoln, NE: iUniverse.
  30. 30. FOOD & MOOD – Carbohydrates • High levels of serotonin: • impulse control, relaxation, ability to sleep • irritability, depression, cravings for sweets, tendency towards aggression • Low levels of serotonin: • Chronic insomnia, eating disorders, low sensitivity to pain, problems processing sensory information Leyse-Wallace, R. (2008). Linking nutrition to mental health. Lincoln, NE: iUniverse.
  31. 31. FOOD & MOOD – Carbohydrates • Serotonin • Feel calm, centered • Recognition due to popularity of SSRI anti-depressants • Stress • Depletes serotonin availability • Carb cravings can be caused by serotonin deficiency • Serotonin reduces cravings for CHO • You don’t have to take an antidepressant to boost serotonin Leyse-Wallace, R. (2008). Linking nutrition to mental health. Lincoln, NE: iUniverse.
  32. 32. FOOD & MOOD – Protein • AAs are the building blocks of neurotransmitters including: • Serotonin • Dopamine & Norepinephrine • Acetylcholine (inhibitory/excitatory) • Histamine (inflammatory response) • Glycine (inhibitory) Dekker, T. (2000). Nutrition & recovery. Canada: Centre for Addiction and Mental Health.
  33. 33. FOOD & MOOD – Protein • Two key neurotransmitters: • Dopamine (DA) • “Reward” • Norepinephrine (made from DA) • Mood, role in “fight or flight” • Low levels associated with depression and fatigue
  34. 34. FOOD & MOOD – Protein • Tyrosine
  35. 35. FOOD & MOOD – Protein • Dopamine and norepinephrine are often associated with alcohol / drug abuse Why is low dopamine associated with drug abuse? What can mimic the reward one gets from drug use?
  36. 36. DOPAMINE (DA) • Catecholamine neurotransmitter • Dopamine is the major brain chemical involved in addiction • Important in • Movement (muscle control) • Motivation and attention • Reward • Well-being
  37. 37. FOOD & MOOD – Fat • Essential fatty acids (EFAs): • Linoleic (omega-6) • Linolenic (omega-3) EPA, DHA • Eicosanoid production • Inflammatory processes • Cell membrane integrity • 55%-60% dry wt of brain is lipid • 35% composed of PUFA Fortuna, J. L. (2009). Nutrition for the focused brain. Mason, Ohio: Cengage Learning.
  38. 38. FOOD & MOOD – Fat • Prevalence of depression lower as fish consumption increases (omega-3)1 • Deficiencies alter fluidity in membranes affecting neurotransmission • Protective effect on bipolar, depression Omega-3 & depression now controversial2 “Publication bias” ??? 1. Leyse-Wallace, R. (2008). Linking nutrition to mental health. Lincoln, NE: iUniverse. 2. Bloch, M. H., & Hannestad, J. (2012). Omega-3 fatty acids and the treatment of depression: Systematic review and meta-analysis. Molecular Psychiatry, 17(12), 1272-1282. doi:10.1038/mp.2011.100
  39. 39. FOOD & MOOD – Fat • Low plasma cholesterol associated with depression1 and anxiety2 • Part of every cell membrane • Building block for hormones • Statins??? CONCLUSION: • Fat supports mental health! 1. Leyse-Wallace, R. (2008). Linking nutrition to mental health. Lincoln, NE: iUniverse. 2. Carson, R, E. (2012). The brain fix. Deerfield, FL: Health Communication, Inc.
  40. 40. FACTORS THAT REGULATE FOOD INTAKE • Caloric requirements • Reinforcing responses • Palatability • Conditioned responses • Cues • Cognitive control • Inhibition/regulation
  41. 41. LET’S BE CLEAR BEFORE MOVING ON… The most substantial health burden arising from drug addiction lies not in the direct effects of intoxication but in the secondary effects on physical health Ersche, K. D., Stochl J., Woodward, J. M., & Fletcher, P. C. (2013). The skinny on cocaine. Insights into eating behavior and body weight in cocaine-dependent men. Appetite. Advance online publication. Retrieved from http://dx.doi.org/10.1016/j.ap pet.2013.07.011
  42. 42. POLY-SUBSTANCE ABUSE • 24-hr recalls of 20 F IV drug users revealed > ½ of foods consumed not classifiable into “food groups”1 • Preference for easily ingested/digested foods (i.e. cereal) • Difficulty w/ raw vegetables & meat Digestive issues & preference for hedonistic foods rich in sugar/salt/fat 1. Baptiste, F., & Hamelin, A. (2009). Drugs and diet among women street sex workers and injection drug users in Quebec city. Canadian Journal of Urban Research, 18(2), 78-95.
  43. 43. POLY-SUBSTANCE ABUSE • Added sugar 30% intake of drug addicts in Norway (n=220)1 • Sugar & sugar-sweetened foods preferred > 60% of respondents • 70% vit. D deficiency • Low levels of vit. C • Elevated serum Cu 1. Saeland, M., Haugen, M., Eriksen, F. L., Wandel, M., Smehaugen, A., Bohmer, T., & Oshaug, A. (2011). High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. British Journal of Nutrition, 105, 618-624. doi:10.1017/S0007114510003971
  44. 44. POLY-SUBSTANCE ABUSE • > ½ detox patients deficient in either iron or vitamins, particularly A and C1 • Low K associated w/ alcohol- dependence • Prevalence of malnutrition likely underestimated • Oral MVI & parenteral thiamine upon admission 1. Ross, L. J., Wilson, M., Banks, M., Rezannah, F., & Daglish, M. (2012). Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment. Nutrition, 28, 738-743. doi:10.1016/j.nut.2011.11.003
  45. 45. POLY-SUBSTANCE ABUSE • Significantly low vit. A, C, E levels compared to non-addict controls1 • Antioxidant vitamins • Increased copper2,3 • Inflammation? • Increased zinc2 1. Islam, S. K. N., Hoassain, K. J., & Ahsan, M. (2001). Serum vitamin E, C, and A status of the drug addicts undergoing detoxification: influence of drug habit, sexual practice and lifestyle factors. European Journal of Clinical Nutrition, 55, 1022-1027. 2. Hossain, K. J., Kamal, M. M., Ahsan, M, & Islam, S. N. (2007). Serum antioxidant micromineral (Cu, Zn, Fe) status of drug dependent subjects: Influence of illicit drugs and lifestyle. Substance Abuse Treatment, Prevention, and Policy, 2(12). Retrieved from http://www.substanceabusepolicy.com/content/2/1/1 2 • Acute fasting? 3. Saeland, M., Haugen, M., Eriksen, F. L., Wandel, M., • Immune regulation? sugar consumption and poor nutrient intake among • Decrease in iron2,4 • Malnutrition? • Role of other lifestyle factors? Smehaugen, A., Bohmer, T., & Oshaug, A. (2011). High drug addicts in Oslo, Norway. British Journal of Nutrition, 105, 618-624. doi:10.1017/S0007114510003971 4. Ross, L. J., Wilson, M., Banks, M., Rezannah, F., & Daglish, M. (2012). Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment. Nutrition, 28, 738-743. doi:10.1016/j.nut.2011.11.003
  46. 46. OPIATES • Infrequent eating, little interest in food (appetite suppression) • Reduced gastric motility1 • Delayed gastric emptying • Impaired gastrin release • Constipation while using • Diarrhea while detoxing • GI discomfort for several months • Compromised gut health Impaired absorption of AA, vit/min 1. White, R. (2012). Drugs and nutrition: How side effects can influence nutritional intake. Proceedings of the Nutrition Society, 69, 558-564. doi:10.1017/S0029665110001989
  47. 47. Nakah, A. E., Frank, O., Louria, D. B., Quinones, M. A., Baker, H. (1979). A vitamin profile of heroin addiction. American Journal of Public Health, 69(10), 1058-1060. • Classic heroin study • n = 149 • 45% deficient in vitamin B6 • Replicated in 19811 • 37% deficient in folate • Replicated in 20042 • 19% deficient in thiamine • Elevated Mg and Phos in methadone patients2 1.Heathcote, J., & Taylor, K. B. (1981). Immunity and nutrition in heroin addicts. Drug and alcohol dependence, 8, 245-255 2. Estevez, J. F. D., Estevez, F. D., Calzadilla, C. H., Rodriquez, E. M. R., Romero, C. D., & SerraMajem, L. (2004). Application of linear discriminant analysis to the biochemical and haematological differentiation of opiate addicts from healthy subjects: A case-control study. European Journal of Clinical Nutrition, 58, 449455. doi:10.1038/sj.ejcn.1601827
  48. 48. OPIATES • Quick, convenient, cheap, sweet foods1 • Low fiber • Easily digestible • Calorically dense Ice cream! • Fruit/vegetable consumption generally low 1. Neale, J., Nettleton, S., Pickering, L., & Fischer, J. (2012). Eating patterns among heroin users: a qualitative study with implications for nutritional interventions. Addiction, 107, 635-641. doi:10.1111/j.1360-0443.2011.03660.x
  49. 49. Varela, P., Marcos, A., Santacruz I., Ripoll, S., & Requejo A. M. (1997). Human immunodeficiency virus infection and nutritional status in female drug addicts undergoing detoxification: anthropometric and immunologic assessments. American Journal of Clinical Nutrition, 66, 504S-508S. • Malnutrition present in all 36 heroin addicted females prior to quitting • After 6 months detoxification: adequate recovery of nutrition status, including those with HIV • Authors recommend nutrition education as early as possible to help patients get free of drug habits, and contribute significantly to an improved quality of life
  50. 50. OPIATES – TREATMENT RESEARCH • Methadone-treated patients1 • Higher consumption of sweets • Higher eagerness to consume sweet foods • Willingness to consume larger quantities desired by controls • Qualitative research on heroin users confirmed2 • Dysfunctional eating patterns 1. Nolan, L. J., & Scagnelli, L. M. (2007). Preference for sweet foods and higher body mass index in patients being treated in long-term methadone maintenance. Substance Use and Misuse, 42, 1555-1566. doi:10.1080/10826080701517727 2. Neale, J., Nettleton, S., Pickering, L., & Fischer, J. (2012). Eating patterns among heroin users: a qualitative study with implications for nutritional interventions. Addiction, 107, 635-641. doi:10.1111/j.1360-0443.2011.03660.x
  51. 51. METHADONE • Osteopenia or osteoporosis in relatively young sample (37 ± 7 yrs)1 • Low levels of circulating luteinizing hormone, estrogen, and testosterone, or impaired adrenal function may be contributing mechanisms • Confounders not adequately controlled Further study: hormones 1. Dursteler-Macfarland, K. M., Kowalewski, R., Bloch, N., Wiesbeck, G. A., Kraenzlin, M. E., & Stohler, R. (2010). Patients on injectable diacetylmorphone maintenance have low bone mass. Drug and alcohol review, 30, 577-582. doi:10.1111/j.14653362.2010.00242.x
  52. 52. METHADONE • Basal leptin and adiponectin significantly decreased, resistin increased1 • Independent of BMI, body fat, and insulin sensitivity • Lower serum leptin may contribute to immune dysfunction2 • Proposed trials involving gene therapy aimed at reinstating leptin circuitry in drug addicts3 1. Housova, J., Wilczek, H., Haluzik, M. M., Kremen, J., Krizova, J., & Haluzik, M. (2005). Adipocyte-derived hormones in heroin addicts: The influence of methadone maintenance treatment. Physiological Research, 54, 73-78. 2. Sanchez-Margalet, V., Martin-Romero, C., Santos-Alvarez, J., Goberna, R., Najib, S., & Gonzalez-Yanes, C. (2003). Role of leptin as an immunomodulator of blood mononuclear cells: mechanisms of action. Clinical and Experimental Immunology, 133(1), 11-19. 3. Kalra, S. P. (2012). Leptin gene therapy for hyperphagia, obesity, metabolic diseases, and addiction. In Brownell, K. D., & Gold, M. S., Food and addiction (131-137). New York, NY: Oxford University Press.
  53. 53. STIMULANTS • Many ED patients gravitate towards their use (appetite suppression) • Daily users more likely to snack than eat meals • Constricted throat muscles? • Post-using (“come down”) bingeeating behavior • Use again as compensatory purge • ED vs. SUD vs. Dual-Diagnosis
  54. 54. COCAINE • Reduced appetite, nausea • Affinity for high-sugar food/drink1 • Addicts in detox prefer highest conc. of sucrose solution offered • Brain reward (dopamine) • In large national sample, cocaine users more likely to have heroin or meth2 CKD or CVD BP than 1. Janowsky, D. S., Pucilowski, O., & Buyinza, M. (2003). Preference for higher sucrose concentrations in cocaine abusingdependent patients. Journal of Psychiatric Research, 37, 35-41. 2. Akkina, S. K., Ricardo, A. C., Patel, A., Das, A., Bazzano, L. A., Brecklin, C. ...Lash, J. P. (2012). Illicit drug use, hypertension, and chronic kidney disease in the US adult population. Translational Research, 160(6), 391-398.
  55. 55. Ersche, K. D., Stochl J., Woodward, J. M., & Fletcher, P. C. (2013). The skinny on cocaine. Insights into eating behavior and body weight in cocaine-dependent men. Appetite. Advance online publication. Retrieved from http://dx.doi.org/10.1016/j.appet.2013.07.011 • Cocaine-dependent men reported increased food intake, specifically foods high in fat and carbohydrate • Trend towards lower levels of circulating leptin in the cocaine group, directly interfering with metabolic processes • Overeating in cocaine-dependent individuals pre-dates recovery, with the effect masked by lack of weight gain • Taken together, cocaine abuse results in imbalance between fat intake and storage, leading to excessive weight gain during recovery
  56. 56. COCAINE • Low levels of omega-3 and omega-6 linked to relapse1 • May stem from increased anxiety associated w/ low PUFA2 • Omega-3 PUFAs used in treatment for depression3 • Addiction stripping brain EFAs4 • Impaired utilization of AAs for NT synthesis (dopamine, serotonin) • Amino acid therapy??? 1. Buydens-Branchey, L., Branchey, M., McMakin, D. L., & Hibbeln, J. R. (2003). Polyunsaturated fatty acid status and relapse vulnerability in cocaine addicts. Psychiatry Research, 120, 29-35. doi:10.1016/S0165-1781(03)00168-9 2. Buydens-Branchey, L., & Branchey, M. (2006). N-3 polyunsaturated fatty acids decrease anxiety feelings in a population of substance abusers. Journal of Clinical Psychopharmacology, 26(6). doi:10.1097/01.jcp.0000246214.49271.fl 3. Ross, B. M., Seguin, J., & Sierwerda, L. E. (2007). Omega-3 fatty acids as treatments for mental illness: Which disorder and which fatty acid? Lipids in Health and Disease, 6(21), doi:101.1186/1476-511X-6-21 4. 1. Grotzkyj-Giorgi, M. (2009). Nutrition and addiction – can dietary changes assist with recovery?. Drugs and Alcohol Today, 9(2), 24-28.
  57. 57. COCAINE – AMINO ACID THERAPY? • N-acetylcysteine (NAC) • Proposed pharmacological treatment for relapse prevention1 • Evidence suggesting long-term efficacy of therapeutic AA programs is lacking • Need more controlled trials • Increasing overall protein can promote NT synthesis is less urgent manner • Assuming addict is safe and food is available Long-term sustainable behavior change 1. LaRowe, S. D., Myrick, H., Hedden, S., Mardikian, P., Saladin, M., McRae, A., ...Malcolm, R. (2007). Is cocaine desire reduced by nacetylcysteine? American Journal of Psychiatry, 164(7), 1115-1117.
  58. 58. METHAMPHETAMINE • Disrupts energy metabolism1 • Changes in gene expression and proteins associated with muscular homeostasis/contraction • Maintenance of oxidative status • Oxidative phosphorylation • Fe and Ca homeostasis • Ferritin down regulation free iron • Harmful free radicals via Fenton rxn • Pyruvate pathways diverted towards fermentation to lactic acid 1. Sun, L., Li, H., Seufferheld, M .J., Walters Jr., K. R., Margam, V. M., Jannasch, A., ...Pittendrigh, B. R. (2011). Systems-scale analysis reveals pathways involved in cellular response to methamphetamine. Insights into Methamphetamine Syndrome, 6(4), e18215.
  59. 59. METHAMPHETAMINE • > 40% meth users had dental/oral dz1 • Almost 60% had missing teeth • IV users higher rates of dental dz compared to smoking/snorting, and to other IV drugs2 • Altered Ca utilization?3 • High intake refined CHO, high calorie carbonated beverages, increased acidity in oral cavity, GI regurgitation/vomiting4 “Meth mouth” 1. Shetty, V., Mooney, L. J., Zigler, C. M., Belin, T. R., Murphy, D., & Rawson, R. (2010). The relationship between methamphetamine use and increased dental disease. Journal of the American Dental Association, 141(3), 307-318. 2. Laslett, A., Dietze, P., & Dwyer, R. (2008). The oral health of streetrecruited injecting drug users: Prevalence and correlates of problem. Addiction, 103, 18211825. doi:10.1111/j.13600443.2008.02339.x 3. Sun, L., Li, H., Seufferheld, M .J., Walters Jr., K. R., Margam, V. M., Jannasch, A., ...Pittendrigh, B. R. (2011). Systems-scale analysis reveals pathways involved in cellular response to methamphetamine. Insights into methamphetamine syndrome, 6(4), e18215. 4. Hamamoto, D. T., & Rhodus, N. L. (2009). Methamphetamine abuse and dentistry. Oral Diseases, 15, 2737. doi:10.1111/j.16010825.2008.01459.x
  60. 60. METHAMPHETAMINE • Cessation and subsequent improvements in nutrition and oral hygiene 1st line of treatment • Oral health affects capacity to consume food, therefore… • Potential impact all areas of nutrition • Interventions must be realistic! • Monitor/evaluate xerostomia, chewing ability, and taste Consumption of refined CHO • Replace with fruits/vegetables
  61. 61. METHAMPHETAMINE • Animal models: • Antioxidant Se plays protective role in methinduced neurotoxicity1 • Co-Q10 shown to attenuate meth and cocaine neurotoxicity2 1. Imam, S. Z., & Ali, S. F. (2000). Selenium, an antioxidant, attenuates methamphetamineinduced dopaminergic toxicity and peroxynitrite generation. Brain Research, 855, 186-191. 2. Klongpanichapak, S., Govitrapong, P., Sharma, S. K., & Edabi, M. (2006). Attenuation of cocaine and methamphetamine neurotoxicity by coenzyme Q10. Neurochemical Research, 31, 303311. doi:10.1007/s11064-005-9025-3
  62. 62. AUD – DISORDERED EATING • Sobriety time was positively associated with increased sugar use1 • Documented preferences for sweets in abstinent alcoholics2 • “The use of sweets was often helpful, of course depending upon a doctor’s advice.” –AA Big Book, p. 133 1. Levine, A. S., Kotz, C. M., & Gosnell, B. A. (2003). Sugar and fats: The neurobiology of preference [Special section]. Journal of Nutrition, 831S-834S. 2. Krahn, D., Grossman, J., Henk, H., Mussey, M., Crosby, R., & Gosnell, B. (2006). Sweet intake, sweet-liking, urges to eat, and weight change: relationship to alcohol dependence and abstinence. Addictive Behaviors, 31, 622-631. doi:10/1016/j.addbeh.2005.05.056
  63. 63. Wiss, D. A. (2013). Nutrition and substance abuse (Master's thesis). Retrieved from http://hdl.handle.net/10211.2/3444 • Individuals with a history of substance abuse reported more difficulty controlling overeating when depressed (p = 0.052) • Findings in agreement with previous research associating impulsivity when distressed with problem alcohol users who binge-eat1 • AUDs linked with elevated BMIs2,3 • Higher sweet preference w/ recovering addicts4,5,6 • Likely to be with food that is associated with increased dopamine activity in the brain • Sugar has been identified as having the most rewarding properties in the mesolimbic dopaminergic system7 • Abstinence from alcohol/drugs results in cravings for other mood-altering substances in order to counteract the associated depression. These habits persist well after abstinence has been achieved, and in many cases the habitual overeating worsens over time7 1. Fischer, S., Anderson, K. G., & Smith, G. T. (2004). Coping with distress by eating or drinking: Role of trait urgency and expectancies. Psychology of Addictive Behaviors, 18(3), 269-274. doi:10.1037/0893-164X.18.3.269 2. Barry, D., & Petry, N. M. (2009). Associations between body mass index and substance use disorders differ by gender: Results from the national epidemiological survey on alcohol and related conditions. Addictive Behavior, (34)1, 51-60. doi:10.1016/j.addbeh.2008.08.008 3. Petry, N. M., Barry, D., Pietrzak, R. H., & Wagner, J. A. (2008). Overweight and obesity are associated with psychiatric disorders: results from the national epidemiological survey on alcohol and related conditions. Psychosomatic Medicine, 70, 288-297. doi:10.1097/PSY.0b013e3181651651 4. Krahn, D. D. (1991). The relationship of eating disorders and substance abuse. Journal of Substance Abuse, 3(2), 239-253. 5. Nolan, L. J., & Scagnelli, L. M. (2007). Preference for sweet foods and higher body mass index in patients being treated in long-term methadone maintenance. Substance Use and Misuse, 42, 15551566. doi:10.1080/10826080701517727 6. Saeland, M., Haugen, M., Eriksen, F. L., Wandel, M., Smehaugen, A., Bohmer, T., & Oshaug, A. (2011). High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. British Journal of Nutrition, 105, 618-624. doi:10.1017/S0007114510003971 7. Levine, A. S., Kotz, C. M., & Gosnell, B. A. (2003). Sugar and fats: The neurobiology of preference [Special section]. Journal of Nutrition, 831S-834S.
  64. 64. SUD – DISORDERED EATING • Women in SUD treatment1 • BED and sub-threshold BED • Bulimia nervosa • Men in SUD treatment2 • First 6 months • Bingeing • Use of food to satisfy drug cravings • 7-36 months • Weight concerns, distress about efforts to lose weight 1. Czarlinksi, J. A., Aase, D. M., & Jason, L. A. (2012). Eating disorders, normative eating self-efficacy and body image self-efficacy: Women in recovery homes. European Eating Disorders Review, 20, 190-195. 2. Cowan, J., & Devine, C. (2008). Food, eating, and weight concerns of men in recovery from substance addiction. Appetite, 50, 33-42. doi:10.1016/j.appet.2007.05.006
  65. 65. DISORDERED EATING • Body image issues often relevant to both AUD/SUD patients • Does not always imply presence of ED • Early recovery is stressful! • Craving, compulsivity • Relapse risk • Substance abuse linked to low distress tolerance leading to consumption of food1 • Night Eating Syndrome 1. Kozak, A. T., & Fought, A. (2011). Beyond alcohol and drug addiction. Does the negative trait of low distress tolerance have an association with overeating? Appetite, 57, 578-581. doi:10.1016/j.appet.2011.07.008
  66. 66. DEFINING ADDICTION & FOOD American Society of Addiction Medicine (ASAM) “addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry” ASAM recognizes food as having addictive potential Food (Wikipedia) (Noun): Any nutritious substance that people or animals eat or drink, or that plants absorb, in order to maintain life and growth. Food in it’s natural state is hardly addictive… But what about highly concentrated byproducts of food? aka processed food?
  67. 67. COCA LEAF VS. CRACK COCAINE Coca Leaf Powder Cocaine Crack Cocaine • Not highly addictive • By-product • Addictive • Further processed • Wreaks havoc on human brain
  68. 68. POPPY PLANT VS. HEROIN Poppy Plant Raw opium Heroin • Not highly addictive • By-product • Addictive • Further processed • Highly Addictive
  69. 69. WHEAT PLANT VS. WHITE FLOUR Wheat Plant • Not addictive Whole Wheat Flour Refined White Flour • By-product • Further Processed • “Offensive”
  70. 70. CORN VS. HIGH FRUCTOSE CORN SYRUP (HFCS) Corn Corn Syrup HFCS • Not addictive • By-product • Further Processed • “Offensive”
  71. 71. Katherine, A. (1991). Anatomy of a food addiction (3rd ed.). Carlsbad, CA: Gurze Books. • “A food addict knows which foods hold a charge and which do not” • “The same food can be nonaddictive in small doses and highly addictive when too much is eaten”
  72. 72. Kessler, D. A. (2009). The end of overeating. New York, NY: Rodale Inc. • “Hyperpalatable food” • “Some people are likelier than others to find food more reinforcing and are thus more willing to work harder to obtain it.” • “Conditioned hypereating” • “Over time, a powerful drive for a combination of sugar, fat, and salt competes with our conscious capacity to say no.”
  73. 73. WHAT IS A “FOOD ENVIRONMENT”? • Collection of physical, biological, and social factors affecting eating habits/patterns • Access to food • “Food Deserts” convenience foods • Resource limitations? • Food availability (rehab or sober living) • Environmental causes of overeating? • Highly available “hyperpalatable” foods a risk factor for food addiction in some individuals? • “Big Food” aka The Food Industry created irresistible, yet toxic “Food Environment”?
  74. 74. FOOD ADDICTION – CULPRITS • Sugar, Salt, Fat • The more multisensory the food the more likely a person is to crave it • Combining a cold food such as ice cream with a warm sauce such as hot fudge, and topping it off with smooth peanut butter cups and crunchy heath bar pieces becomes IRRESISTIBLE
  75. 75. FOOD ADDICTION – CULPRITS What is the difference between a baked potato and French fries with ketchup? Fat…Salt…Sugar
  76. 76. FOOD ADDICTION – CULPRITS Refined grains… w/ sugar/salt/fat
  77. 77. THE CONTROVERSY OF FOOD ADDICTION • Is overeating a behavioral problem or a substance related problem? • Does obesity stem from high-risk people or high-risk foods? • Abstinence from offending “drug foods”? • Risk factor for binge eating? • Or abstinence from offending behaviors? • Classic ED treatment
  78. 78. ACADEMY OF NUTRITION AND DIETETICS ON FOOD ADDICTION • “Total Diet Approach”1 • Rejects labeling foods as “good” and “bad” because it is believed to foster unhealthful eating behaviors • Unless contraindicated by extenuating circumstances • “Sugar addiction present in humans has not been proven”2 1. Academy of Nutrition and Dietetics (2013). Position of the American Dietetic Association: Total diet approach to communicating food and nutrition information. Journal of the American Dietetic Association, 113(2), 307-317. 2. Academy of Nutrition and Dietetics (2012). Position of the Academy of Nutrition and Dietetics: Use of nutritive and nonnutritive sweeteners. Journal of the Academy of Nutrition and Dietetics, 112(5), 739-758.
  79. 79. YALE FOOD ADDICTION SCALE (YFAS) • Developed in 2008, both internally & externally validated1 • Abnormal desire for sweet, salty, and fatty foods documented in obese adults using YFAS2 • Diagnostic scoring based on seven symptoms in the DSM-IV-TR for substance dependence • Withdrawal • Tolerance • Use despite negative consequences • Food addiction found in 57% of obese BED patients3 1. Gearhardt, A. N., Corbin, W. R., & Brownell, K. D. (2009). Preliminary validation of the Yale food addiction scale. Appetite, 52, 430-436. doi:10.1016/j.appet.2008.12.003 2. Davis, C., Curtis, C., Levitan, R. D., Carter, J. C., Kaplan, A. S., & Kennedy, J. L. (2011). Evidence that ‘food addiction’ is a valid phenotype of obesity. Appetite, (57), 711-717. doi:10.1016/j.appet.2011.08.017 3. Gearhardt, A. N., White, M. A., Masheb, R. M., Morgan, P. T., Crosby, R. D., & Grilo, C. M. (2012). An examination of the food addiction construct in obese patients with binge eating disorder. International Journal of Eating Disorders, 45, 657-663. doi:10.1002/eat.20957
  80. 80. BINGE EATING DISORDER (BED) • Etiology of BED poorly understood • DA involved in regulating “food motivation” for food intake • Could brain DA be involved in motivation for food consumption explain behavior in BED?
  81. 81. FOOD ADDICTION • Stressing “moderation” to addicts is a moot point because the prefrontal cortex function is severely impaired1 • The message of “get it together,” “stop eating so much,” and “just become an intuitive eater” is not helpful2 • “Food can act on the brain as an addictive substance. Certain constituents of food, sugar in particular, may hijack the brain and override will, judgment, and personal responsibility, and in so doing create a public health menace.”3 • “Food addiction” versus “food and addiction”3 1. Goldstein, R. Z., & Volkow, N. D. (2011). Dysfunction of the prefrontal cortex in addiction: Neuroimaging findings and clinical implications. Nature Reviews Neuroscience, 12(11), 652-669. doi:10.1038/nrn3119 2. Peeke, P. (2012). The hunger fix. New York, NY: Rodale. 3. Brownell, K. D., & Gold, M. S. (2012). Food and addiction. New York, NY: Oxford University Press.
  82. 82. Peeke, P. (2012). The hunger fix. New York, NY: Rodale. • “False Fixes” • Use of food to fix unpleasant feelings • Expecting a food addict to kick their habit by examining food labels is like expecting a crack addict to get clean after attending a lecture on the dangers of cocaine • Detox stage • Recovery stages • Overall eating plan
  83. 83. WHY DO RECOVERING ADDICTS GAIN WEIGHT? • “Drugs exert such a strong reinforcing influence on the pathways in the brain that weaker reinforcing signals, such as those from food, are ignored and fail to motivate behavior” • Appetite and taste returns in the post-drug state Blumenthal, D. M., & Gold, M. S. (2012). Relationship between drugs of abuse and eating. In Brownell, K. D., & Gold, M. S., Food and addiction (pp. 254-265). New York, NY: Oxford University Press.
  84. 84. BARIATRIC SURGERY AND ALCOHOL • 2458 participants @ 10 US Hospitals • Preoperative/Postoperative Alcohol Use Disorder (AUD) assessment • No significant changes 1st year post-op • Significantly higher in 2nd post-op year • Specifically Roux-en-Y Gastric Bypass (RYGB) • Associated w/ males and younger age • in alcohol sensitivity following bypass King, W. C., Chen, J., Mitchell, J. E., Kalarchian, M. A., Steffen, K. J., Engel, S. G., …Yanovski, S. Z. (2012). Prevalence of alcohol use disorders before and after bariatric surgery. Journal of the American Medical Association. Advance online • Filling the food void? Cross-addiction? publication. Retrieved from http://jama.jamanetwork.com
  85. 85. Burger, K. S., & Stice, G. (2012). Frequent ice cream consumption is associated with reduced striatal response to receipt of an ice-cream based milkshake. The American Journal of Clinical Nutrition, 95(4). doi:10.3945/ajcn.111.027003 • Frequent consumption of ice cream is related to a reduction in reward-region response, in a fashion that parallels drug addiction, independent of body fat • To achieve the same level of reward, a person needs to eat a greater amount of rewarding food, indicating tolerance and addictive potential Changes in brain chemistry can create a higher preference for high-sugar, highsodium, and high-fat foods
  86. 86. FOOD ADDICTION – MORE EVIDENCE • “Reward deficiency syndrome”1 1. Blum, K., Sheridan, P. J., Wood, R. C., Braverman, E. R., Chen, T. J. H., Cull, J. G., & • DA D2 sites linked to substance-seeking behavior Comings, D. E. (1996). The D2 dopamine receptor gene as a determinant of reward • Positron Emission Tomography (PET)2 deficiency syndrome. Journal of the Royal Society of Medicine, 89, 396-400. • Exploring role of DA in mediating “food motivation” to explain excess food consumption in patients with BED3 2. Volkow, N. D., Fowler, J. S., & Wang, G. J. (2003). The addicted human brain: insights from imaging studies. Journal of Clinical Investigation, 111, 1444-1451. doi:10.1172/JCI200318533 • Compulsive overeaters share many of the 3. Wang, G. J. (2012, October). Can people get addicted to palatable food? Food and same imaging characteristics as drug Nutrition Conference and Expo. Symposium conducted at the meeting of The Academy of addicts3 Nutrition and Dietetics, Philadelphia: PA.
  87. 87. MAKING PEACE WITH FOOD • Liberalize? • Some people are able to call a truce with the “food police” • Give themselves “unconditional permission to eat” and become an “Intuitive Eater” • Restrict? • Other people make peace with food by deciding they are powerless over certain foods • Achieve “abstinence”
  88. 88. FOOD ADDICTION LIKE DRUG ADDICTION Restrictors & “falling off the wagon” • “Since I messed up on my plan, I might as well binge/use now because after today I won’t be able to eat/use this way ever again” • “This is the last time I will eat/use this” • “Monday I will start again” • “What’s the use anyhow?” • “I’m a failure”
  89. 89. FOOD-RELATED 12-STEP SUPPORT • Overeaters Anonymous (OA) • OA-HOW • Food Addicts Anonymous • Food Addicts in Recovery Anonymous • Compulsive Eaters Anonymous • Greysheeters Anonymous • Eating Disorders Anonymous
  90. 90. FOOD ADDICTS ANONYMOUS (FAA) FAA is an organization that believes: • Food Addiction is a biochemical disorder that occurs at a cellular level and therefore cannot be cured by willpower or by therapy alone • Food addiction is not a moral/character issue • Food addiction can be managed by abstaining from (eliminating) addictive foods, following a program of sound nutrition (a food plan), and working the Twelve Steps of the program • After we have gone through a process of withdrawal from addictive foods many of us have experienced miraculous life-style changes www.foodaddictsanonymous. org FAA is self-supporting through our own contributions. There are no dues or fees required for membership, but only a desire to stop eating addictive foods. We are not affiliated with any diet or weight loss programs, treatment facilities or religious organizations. We neither endorse nor oppose any causes. Our primary purpose is to stay abstinent and help other food addicts to achieve abstinence.
  91. 91. LET’S BE PRACTICAL – BIG PICTURE • Much like tobacco and caffeine, hyperpalatable food may have beneficial functions in early recovery! • First issue is always to get the individual past the immediate crisis… • “Many of us have noticed a tendency to eat sweets and have found this practice beneficial.” –AA Big Book, p. 134 • Prolonged abuse after abstinence achieved may contribute to: • Comorbid conditions • Compromised quality of life • Decreased likelihood of long-term recovery • Overall healthcare burden
  92. 92. Witherly, S. A. (2007). Why humans like junk food. New York, NY: iUniverse, Inc. “Pleasure is the major driver of food ingestion and behavior, but without an understanding of the nature of food pleasure and perception itself, no useful modification to food can be made. Salt, fat, and sugar, classically considered a nutritional enemy, can still be used for good.”
  93. 93. SO WHAT ARE YOU SAYING? • Liberalized diet including abnormal amounts of sugar during first weeks of abstinence can assuage painful symptoms of withdrawal • Consumption behavior should be monitored and eventually sugar use should be reduced • Assessed individually
  94. 94. “SOCIAL DRUGS” CAFFEINE AND NICOTINE • Used together for synergistic effects • Caffeine as cue for nicotine • Some treatment centers do not allow “social drugs,” others allow without any formal regulation • Often used as a breakfast substitute for individuals in recovery, which may have adverse effects in the afternoon1 1. Dekker, T. (2000). Nutrition and recovery. Toronto, CAN: Centre for Addiction and Mental Health.
  95. 95. CAFFEINE • No longer just coffee, tea, chocolate and sodas • Energy drinks • Workout supplements (>300mg) • Pills • “Caffeinism” 600-750 mg/day • >1000 mg/day defined as toxic1 • Coffee/tea inhibits the absorption of iron in food • Affects duration/quality of sleep 1. Hilton, T. (2007). Pharmacological issues in the management of people with mental illness and problems with alcohol and illicit drug misuse. Criminal Behavior and Mental Health, 17, 215-224. doi:10.1002/cbm.669
  96. 96. NICOTINE Nicotine Introducing the e-cig? • Increases metabolism1 • Acts as appetite suppressant1 • Compromises senses of taste and smell2 Smokers have tendency to choose hyperpalatable snack foods, less likely to enjoy the taste of fruits and vegetables Smokers lower in plasma vitamin C and total carotenoids, independent of dietary intake3 1. Novak, C. M., & Gavini, C. K. (2012). Smokeless weight loss. Diabetes, 61, 776-777. 2. Hatcher, A. S. (2008). Nutrition and addictions. Dallas, TX: Understanding Nutrition, PC. 3. Dekker, T. (2000). Nutrition and recovery. Toronto, CAN: Centre for Addiction and Mental Health.
  97. 97. “SOCIAL DRUG” USE IN EARLY RECOVERY • Timing of caffeine/nicotine reduction or cessation assessed on an individual basis • First few months of sobriety not always optimal time to drastically alter intake • Caffeine abstinence not always indicated • Should be limited to max 450 mg/day (3-4 cups coffee/day) as a reasonable starting goal1 • Nicotine cessation: eventually a goal • Average weight gain of 8-10 lbs. common2 • Recidivism high due to weight concerns 1. Dekker, T. (2000). Nutrition and recovery. Toronto, CAN: Centre for Addiction and Mental Health. 2. Porter, R. S., & Kaplan, J. L. (2011). The merck manual (19th ed.). Whitehouse Station, NJ: Merck Sharpe & Dohme Corp.
  98. 98. “SOCIAL DRUG” USE – CONCLUSIONS • Caffeine and nicotine can impact one’s hunger/fullness cues and lead to dysfunctional eating behavior • Dietitians in treatment settings can help patients meet reduction or cessation goals when ready • By focusing on the benefits of improved physical health, patients will be positioned to make informed choices about what they eat • Strict avoidance of caffeine during early recovery may make nutrition seem punitive vs. a helpful component of recovery • “First things first” – complete avoidance may lead to relapse • Nutrition education and counseling can become an effective adjunctive approach towards caffeine/nicotine reduction/cessation
  99. 99. NUTRITION INTERVENTIONS – GOALS • Primary goal is to support recovery by any means necessary • Complete abstinence from all mindaltering substances • Nutrition therapy emphasizing correction of nutrient deficiencies • Lab data to warrant aggressive interventions
  100. 100. NUTRITION INTERVENTIONS – GOALS • Immediately bombarding an addict entering treatment with pills and other supplements may fail to support behavioral aspects of recovery • If individuals begin using again, efforts to correct nutritional deficiencies are futile, and are likely to redevelop!
  101. 101. NUTRITION INTERVENTIONS – DATA • Positive association between nutrition intervention and substance abuse treatment outcomes within VA system1 • Nutrition education was the differentiating factor • Educational intervention on the nutrition behavior of 58 alcohol dependent patients in Italy2 • After 6 months, 80% reported continuous abstinence 1. Grant, L. P. (2004). Nutrition education intervention and substance abuse treatment outcomes (Doctoral dissertation). Retrieved via California State University Northridge. The University of Tennessee, Knoxville. 2. Barbadoro, P., Ponzio, E., Pertosa, M. E., Aliotta, F., D’Errico, M. M., Prospero, E., & Minelli, A. (2010). The effects of educational intervention on nutritional behaviour in alcohol-dependent patients. Alcohol and Alcoholism, 46(1), 77-79. doi:10.1093/alcalc/agq075
  102. 102. MORE INTERVENTIONS – DATA RHEALTH (Recovery Healthy Eating and Active Learning in Treatment Houses) in Upstate NY1 • 6-week environmental/educational intervention to improve dietary intake & body composition (reduce excessive wt gain among men in residential treatment) • Six sites, n=107 • 55 men provided baseline & post-intervention data • Greater reductions in total energy, percentage of energy 1. Cowan, J. A., & Devine, C. M. from sweets, daily servings of fat/oils/sweets, BMI (2012). Process evaluation of an • Provides evidence that educational and environmental environmental and educational intervention in residential drug- intervention can be successful despite challenges met in treatment facilities. Public Health residential substance abuse treatment facilities Nutrition, 15, 1159-1167. doi:10.1017/S1368980012000572
  103. 103. PRISON INTERVENTIONS – DATA • Drug-addicted prison pop. in the UK1 “The introduction of healthier food and healthy eating advice is overall likely to make sound economic sense in terms of prisoners’ physical health, mood, and behavior.” • Substance Abuse Program (SAP) in US state prison system2 • Series of nutrition workshops led to: • Nutrition improved (p=.047) • General health improved (p=.002) • Social ties improved (p=.18) 1. Sandwell, H, & Wheatley, M. (2009). Healthy eating advice as part of drug treatment in prisons. Prison Service Journal, 182, 15-26. 2. Curd, P., Ohlmann, K., & Bush, H. (2013). Effectiveness of a voluntary nutrition education workshop in a state prison. Journal of Corrective Health Care, 19(2), 144-150. doi:10.1177/107/1078345812474645
  104. 104. SELF-CARE AND GENDER • Food decisions of greater importance and relevance for females. Food choices deeply rooted in gender ideology1 • Men less aware of the association between nutrition, health, and development of disease2 • Male tendency to minimize or conceal medical problems3 • Men less likely to seek treatment for ED4 • Unfavorable male attitudes towards help- seeking5 1. Levi, A., Chan, K. K., & Pence, D. (2006). Real men do no read labels: The effects of masculinity and involvement on college students’ food decisions. Journal of American College Health, 55(2), 91-98. 2. Kiefer, I., Rathmanner, T., & Kunze, M. (2005). Eating and dieting differences in men and women. Journal of Men’s Health and Gender, 2(2), 194-201. 3. Straussner, S. L. A., & Zelvin, E. (1997). Gender and Addictions. Northvale, New Jersey: Jason Aronson Inc. 4. Weltzin, T. E., Cornella-Carlson, T., Fitzpatrick, M. E., Kennington, B., Bean, P., & Jefferies, C. (2012). Treatment issues and outcomes for males with eating disorders. Eating Disorders: The Journal of Treatment & Prevention, 20(5), 444-459. doi:10.1080/10640266.2012.715527 5. Vogel, D. L., Heimerdinger-Edwards, S. R., Hammer, J. H., & Hubbard, A. (2011). “Boys don’t cry”: examination of the links between endorsement of masculine norms, self-stigma, and help-seeking attitudes for men from diverse backgrounds. Journal of Counseling Psychology, 58(3), 368-382. doi:10.1037/a0023688
  105. 105. SELF-EFFICACY • Predictive measure of one’s ability to cope w/ everyday obstacles & adapt to stressful life events1 • Reflects degree of self-belief in ability to perform difficult tasks or cope with adversity • Nutrition interventions in substance abuse treatment can focus on rebuilding self-efficacy by creating realistic nutrition goals each week • Consumption of one vegetable not eaten within last year • Consumption of yogurt once per day • Replace sweetened beverage with water once per day Increased self-efficacy related to nutrition may translate into increased self-efficacy regarding abstinence from alcohol and drugs 1. Schwarzer, R., & Jerusalem, M. (1995). Generalized SelfEfficacy scale. In J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: A user’s portfolio. Causal and control beliefs (pp. 35-37). Windsor, UK: NFER-NELSON.
  106. 106. MOTIVATIONAL INTERVIEWING (MI) • Proper education and counseling will have the ability to change clients faulty thinking about nutrition concepts: • Active listening • Open-ended nonjudgmental probing • Affirmations • Reflections and summarizing • Dietitians trained in MI can assist patients overcome barriers and develop a plan in the path towards behavior change1 1. Clairmont, M. A. (2011, May). Substance abuse treatment: RD’s role in recovery programs. Today’s Dietitian, 13(5), 42-46.
  107. 107. WHAT ABOUT EXERCISE? Lifestyle interventions involving both diet and exercise • Exercise supported in treatment of mental illness1 with profound impacts on cognitive abilities2 • Aerobic activity transforms not only body but mind2 • Exercise can help rebuild brain cells killed by alcoholten min. of exercise could blunt an alcoholic’s craving2 • Other benefits: • Increased self-esteem, self-efficacy • Elevated mood • Improved energy and concentration • More relaxing sleep • Relief of tension • Overall “wellness” Integration of exercise along w/ nutrition critical for full recovery from substance abuse 1. Forsyth, A., Deane, F. P., & Williams, P. (2009). Dietitians and exercise physiologists in primary care: Lifestyle Interventions for patients with depression and/or anxiety. Journal of Allied Health, 38(2), e-63-68 2. Ratey, J. J., & Hagerman, E. (2008). Spark. New York, NY: Little, Brown and Company.
  108. 108. BIG PICTURE – GOALS • Not necessarily weight loss • Relapse prevention • Disease prevention • Focus on overall health • Body, mind, spirit • Behavior change • “Sanity restoration” • “Recovery” • Can be difficult to measure Eventually developing a relationship w/ food & exercise that is intuitive/personal • Avoid “quick fix” whenever possible
  109. 109. SUPPLEMENTS VS. FOOD • Supps may give pts idea that as long as they take pills, they do not need to improve their eating habits • Street drugs exert tremendous strain on liver supraphysiological doses of nutrients may actually conflict with healing process • Eating behavior FIRST, supplements SECOND
  110. 110. THE IMPORTANCE OF FIBER • Gradual/progressive reintroduction • Low fiber tolerance creates significant barriers for nutrition therapy involving fruits, vegetables, whole grains, beans • Increase 2-4 g/week to meet recs: • 38 g/day men, 25 g/day women • Ages 14-50 Focus on improved gut health • Optimal absorption of AAs, vits/mins
  111. 111. SUMMARY – NUTRITION THERAPY • Nutritional deficiency lowers antioxidant potential of cells • Increased potential for cell damage • Increased need for antioxidant vitamins A, C, E, selenium • Higher protein needs than general population • Promote NT synthesis
  112. 112. SUMMARY – NUTRITION THERAPY • Ideal macro breakdown • 45-50% CHO • 25-30% protein • 20-30% fat • Of CHO consumed: • 75% unrefined • Whole grain, fruits, vegetables • Dairy (if tolerant) • Some leeway for sugar and refined grains in early recovery
  113. 113. IDEAL TIMELINE – NUTRITION THERAPY • 6 hours • Complete diet liberalization • Micronutrient supplementation • 6 days • Targeted nutrition education • Diet liberalization (goal: improvement) • 6 weeks • Reduce intake of sugar and refined CHO • 6 months • Cessation of supplementation
  114. 114. ABSTINENCE FROM OFFENDING FOODS? • Some binge eaters (highly dysregulated) benefit from restricting added sugars and refined grains • Beware of rebound bingeing • Disordered thinking patterns • “Orthorexia” However, SUD patients should NOT be forced to eat highly palatable refined foods under the guise of protection from potential ED
  115. 115. OTHER RECS – NUTRITION THERAPY • 50% of fruits and vegetables should be raw • Vs. cooked, canned, frozen, dried • Minimal fruit juice • Spotlight on fiber! “Zen Nutrient”1 • Beans, nuts, seeds! • Brazil nuts (Se) 1. Hoffinger, R. (2012). The recovery diet. Avon, MA: Adams Media.
  116. 116. OTHER RECS – NUTRITION THERAPY • Oily fish • Plant-based omega-3’s • Flax seeds, walnuts • Chia seeds! • Dairy choices (go organic!) • Milk, yogurt, cottage cheese • Low protein high-fat cheeses and processed cheeses used sparingly • Alternative milks • Calcium, vitamin D
  117. 117. SUPPLEMENTATION • Compromised GI function may create barriers for absorption of vitamins • Liquid forms useful • Meal replacement drinks • MVI w/ low metal content • Antioxidant supps? • Co-Q10, alpha lipoic acid, resveratrol, flavonoid polyphenols
  118. 118. RECS – POLY-SUBSTANCE ABUSE INVOLVING ALCOHOL • MVI (low metal) • Additional B-vitamins primarily thiamine (for EtOH) • Omega-3 supplement DHA rich • Diet rich in vits A, C, E, Se, Fe • Probiotics if GI distress
  119. 119. RECS – OPIATES • Liquid MVI (low metal) • Additional vit. B6 • Additional calcium and vit. D • Digestive enzymes, probiotics • Fiber supp if constipated • Higher caloric needs? • Diet rich in vits A, C, E, Se, Fe
  120. 120. RECS – COCAINE • MVI (low metal) • Omega-3 supp DHA rich • Protein-rich diet • Diet rich in vits A, C, E, Se, Fe • Gradual weight gain1 • Not drastic/immediate 1. Ersche, K. D., Stochl, J., Woodward, J. M., & Fletcher, P.C. (2013). The skinny on cocaine. Insights into eating behavior and body weight in cocainedependent men. Appetite. Advance online publication. Retrieved from http://dx.doi.org/10.1016/j.appet.2013 .07.011
  121. 121. RECS – METHAMPHETAMINE • MVI (low metal, no Fe) • Omega-3 supp DHA rich • Protein-rich diet • Diet rich in vits A, C, E, Se • Lower refined CHO intake
  122. 122. SOURCES OF VITAMIN A • Carrots • Pumpkin • Sweet Potato • Kale
  123. 123. SOURCES OF VITAMIN C • Bell Peppers • Kiwi • Broccoli • Strawberries
  124. 124. SOURCES OF VITAMIN E • Almonds • Sunflower Seeds • Turnip Greens • Peanut Butter
  125. 125. SOURCES OF SELENIUM • Brazil Nuts • Yellowfin Tuna • Turkey • Halibut
  126. 126. SOURCES OF IRON • Red meat • Lentils • Pumpkin seeds • Kidney beans
  127. 127. NUTRITION IN RECOVERY • Interactive nutrition education course designed for substance abuse treatment centers and “sober living” • Not a traditional “talk therapy” rehab group • Individual concerns deferred to individual counseling if not relevant to topic • Curriculum practical, organized w/in context of recovery • Each class begins with a healthful snack- “hands on” • Handout packets for residents to keep • Informal pop quizzes • Nutrition games
  128. 128. NUTRITION IN RECOVERY Goal: To introduce nutrition as an important component of recovery and to encourage behavior change with respect to food
  129. 129. NUTRITION IN RECOVERY Title: Introductory and Emotional Eating Goal: To familiarize everyone with instructor, and the goals and topics for the upcoming weeks. To conduct informal needs assessment to discover issues needing to be addressed. Objectives: 1. To get residents excited about Nutrition in Recovery. 2. Introduce concepts of food addiction, emotional eating, mindful eating. 3. Explain the difference between the nutrition group and individual counseling. Answer all questions about what to expect.
  130. 130. NUTRITION IN RECOVERY Title: Nutrient Terminology (1) Goal: To expose all participants to the basic terminology regarding macronutrients. Objectives: 1. Define carbohydrate, protein, fat, and all basic terms under each category. 2. Get all participants on the same page with respect to terminology so that we can learn together in an interactive environment. 3. Allow participants to share what they know about these terms using an activity questionnaire in order to assess overall degree of knowledge.
  131. 131. NUTRITION IN RECOVERY Title: Nutrient Terminology (2) Goal: To expose all participants to the basic terminology regarding micronutrients. Objectives: 1. Review macronutrient terminology from previous week. 2. Define/discuss selected terms associated with micronutrients. 3. Quiz participants.
  132. 132. NUTRITION IN RECOVERY Title: MyPlate Goal: To introduce and define the five food groups. Objectives: 1. Introduce the five food groups and MyPlate recommended eating. 2. Address confusion regarding the food classification process using a game. 3. Make practical recommendations for daily eating.
  133. 133. NUTRITION IN RECOVERY Title: Label Reading Goal: To introduce all elements of the nutrition facts panel and front label. Objectives: 1. Examine sample nutrition facts panel and define all terms. 2. Define all Nutrition Labeling and Education Act terms. 3. Quiz participants on material learned today.
  134. 134. NUTRITION IN RECOVERY Title: Alcohol, Drugs, Caffeine, Nicotine Goal: To explore negative nutritional consequences of substances of abuse. Objectives: 1. Introduce concept of primary vs. secondary malnutrition (alcohol and drugs). 2. Discuss “substance substitution” (caffeine and nicotine). 3. Make recommendations for recovery.
  135. 135. NUTRITION IN RECOVERY Title: Strategies for Weight Management Goal: To discuss methods to control overeating and improve daily nutrition habits. Objectives: 1. Introduce principles of weight management. 2. Explore common nutrition mistakes. 3. Quiz participants.
  136. 136. NUTRITION IN RECOVERY Title: Tips, Mistakes, Suggestions Goal: To offer guidance for weight management and overall healthful eating. Objectives: 1. Discuss some weight loss tips. 2. Explore common nutrition mistakes. 3. Discuss favorable food choices. 4. Administer program evaluation.
  137. 137. NUTRITION IN RECOVERY Title: Food and Mood Goal: To explore relationship between nutrition and behavior and make connections with substance abuse recovery. Objectives: 1. Introduce concept of nutrition linked to mental health. 2. Discuss deficiencies associated w/ behavior problems. 3. Recommend foods to help regulate mood. 4. Discuss neurotransmitters. 5. Question/quiz participants.
  138. 138. NUTRITION IN RECOVERY Title: Sugar, Sweetened Beverages, Energy Drinks Goal: To discuss the sugar content of sweetened beverages and the impact of sugar on overall health. Objectives: 1. Administer, discuss, and collect BEVQ-15. 2. Discuss sugar-sweetened beverages and encourage limiting intake. 3. Discuss hidden forms of sugar in foods and beverages.
  139. 139. NUTRITION IN RECOVERY Title: Inflammation, Phytochemicals, Heart Disease Goal: To reinforce the importance of a balanced diet with emphasis on fruits and vegetables. Objectives: 1. To discuss the relationship between inflammation and chronic disease. 2. To explore phytochemical content of plant foods and their benefits. 3. To suggest a heart healthy diet rich in fruits
  140. 140. NUTRITION IN RECOVERY Title: Hormones, Habits Goal: To explore the relationship between hormones and food and provide simple suggestions for creating new habits. Objectives: 1. To discuss the relationship between hormones and food. 2. To explore different food and lifestyle personalities. 3. To provide tips for creating new habits.
  141. 141. NUTRITION IN RECOVERY Title: Sugar, Fat, Salt: Overeating and Food Addiction Goal: To discuss controversy of food addiction and the role of sugar, salt, and fat. Objectives: 1. Introduce concept of carbohydrate addiction and food addiction. 2. Discuss hyper-palatable combinations of sugar, fat, salt. 3. Make recommendations for managing cravings and binge eating.
  142. 142. NUTRITION IN RECOVERY Title: Chronic Disease and Nutrition: Self-Care Goal: To discuss the connection between nutrition and health. Objectives: 1. Discuss common chronic diseases. 2. Describe the link between nutrition and health. 3. Make recommendations for increasing overall wellness.
  143. 143. NUTRITION IN RECOVERY Title: Eating for Exercise Goal: To discuss the basics of preand post-workout nutrition. Objectives: 1. To discuss the role of food as fuel. 2. To describe the role of food in recovery from physical activity. 3. To encourage movement.
  144. 144. NUTRITION IN RECOVERY Title: Nutrition Myths and Trends Goal: To debunk myths associated with nutrition and diet. Objectives: 1. Explore fad diets and why they exist. 2. Discuss current trends in nutrition.
  145. 145. NUTRITION IN RECOVERY Title: Body Image and Disordered Eating Goal: To explore the impact of body image and disordered eating in substance abuse recovery. Objectives: 1. To discuss body image and encourage open participation. 2. To introduce the role of the RD in the treatment of eating disorders. 3. To investigate eating disorders in the male population. 4. To recommend strategies to decrease binge eating. 5. To administer program evaluation.
  146. 146. NUTRITION IN RECOVERY • Intake will address: • Weight history (screen for body image issues) • Diet history (screen for ED/DE) • Health history • GI/bowel function • Substance abuse history • Medications (drug-nutrient interactions) • Supplement use • Caffeine use • Nicotine use • Current eating behaviors (screen for ED/DE) • Food preferences • Intake from food groups • Water and other beverage consumption intake • Physical activity • Assessment/diagnosis (PES statement) Intervention with implementation of food diary? (no calorie counting) Individual Counseling: • Sign up after class for 30 minute session • First session is dedicated to intake and assessment
  147. 147. NUTRITION IN RECOVERY • Follow-up will address: • What went well • What was challenging • Monitoring and evaluation of goals • Sample PES statement: • Food and nutrition-related knowledge deficit (NB-1.1) related to lack of prior exposure to accurate nutrition-related knowledge as evidenced by reports of no prior knowledge of need for food- and nutrition-related recommendations Between 8/10/12 - 3/22/13: 62 sessions with 20 residents
  148. 148. NUTRITION IN RECOVERY – CASE STUDY • Intake 8-10-12 (outpatient) • 27 y/o M h/o heroin/oxycontin/methadone • 5’11” 230 lbs. BMI = 32.1 • 7-11 sandwiches daily • Low fruit/vegetable intake • Long periods w/o eating, overeating at night • We met 7 times • Changes included: breakfast daily, regular eating patterns, increased water consumption, consumption of Greek yogurt, nuts, fish, fruits, vegetables, eliminate “pre-workout formulas” • “5 food groups/day, 5 meals/day <500 calories, 5 500 ml water/day, 5 workouts/week” • Made some exercise recommendations • Outcome as of 3-8-13: 217 lbs. BMI = 30 7-31-13: 201 lbs. BMI = 28.1
  149. 149. NUTRITION IN RECOVERY – CASE STUDY • Intake 8-10-12 (outpatient) • 32 y/o F h/o of meth & bulimia nervosa • 5’6½” 131 lbs. BMI = 20.8 • Chronic dieter, “low carb,” daily weighing • Restricts fruit and grains • We met 17 times • She wanted to run the marathon and asked my opinion…I told her that I would be willing to monitor and evaluate her progress if she agreed to pull out if she regressed into ED behaviors • Outcome: Liberalized dietary intake from all 5 food groups and including salad dressing. As of 3-1-13: 146 lbs. BMI = 23.3 • 3-7-13 LA Marathon (solid recovery: honest, transparent, kept weight on, engaged)
  150. 150. NUTRITION IN RECOVERY Program Evaluation • Shortcomings: • Very few residents will be present for entire course • Nature of addiction treatment unpredictable • Difficult to measure progress in early recovery • People progress through recovery at rates that are individual/personal • Success measured in two ways: • Weekly attendance sheets • Week 1: 3 people Week 7: 15 people • Qualitative questionnaire every 6-8 weeks • Used more for quality improvement than for measurable outcomes
  151. 151. NUTRITION IN RECOVERY Program Evaluation Questions • What have you learned from Nutrition in Recovery? • What more would you like to learn at Nutrition in Recovery? • What is your favorite activity at Nutrition in Recovery? • What is your least favorite activity at Nutrition in Recovery? • What would you do to make Nutrition in Recovery better? • What do you think is Nutrition in Recovery’s impact on this community? • How can Nutrition in Recovery better impact the community? • Has Nutrition in Recovery had an effect on your life? If so, how? • Any other comments?
  152. 152. NUTRITION IN RECOVERY Program Evaluation Positive Feedback: • 9-14-12 • “I think many people are clueless about their nutrition and that Nutrition in Recovery will be beneficial in helping people learn how to feel good without drugs” • “Challenged some of my pre-conceived notions” • “Better informed, more energy” • 11-9-12 • “I think it is very crucial for me to watch what I eat” • “You have made a huge difference in my life and those around me who are serious about change” • “Eating and nutrition education is vital to this community”
  153. 153. NUTRITION IN RECOVERY Program Evaluation Positive Feedback: • 1-18-13 • “More people should come to the group” • “Food is fuel and you need a balanced diet to function properly” • “If the community is better educated on nutrition, then we will have a healthier community” • 3-22-13 • “Need more education for the community” • “Brings awareness about nutrition, and sifts through the myths about nutrition” • “If more people would come to the group it could be great or vast”
  154. 154. WHAT CAN THE RDN DO AS A MEMBER OF THE TREATMENT TEAM? ***Every patient who walks into substance abuse treatment should be assessed by a dietitian*** • Screen for ED and other dysfunctional/disordered food behaviors • Request nutrition-related labs for high-risk patients • Run groups and offer individual counseling • Collect data and publish findings (that means YOU!) • Develop curriculum (use my ideas/suggestions) • Plan special events ex: Supermarket Tours • Attend treatment planning and staff meetings • Work w/ doctors/therapists/counselors to help achieve treatment goals • Nutrition/exercise interventions to facilitate behavior change favorable to long-term recovery and improved quality of life • Audit the menu and suggest substitutions within the budget • Food service and food safety improvements • Work with the chef to improve the “food environment”
  155. 155. Wiss, D. A. (2013). Nutrition and substance abuse (Master's thesis). Retrieved from http://hdl.handle.net/10211.2/3444 CONCLUSIONS OF THESIS: • Depression is one component that can lead to overeating in individuals recovering from substance abuse • The persistence of bad habits not due to an absence of desire for a better life, more likely due to impact of addiction on the brain • Overeating and poor nutrition habits lead to obesity, diabetes, hypertension, and other forms of chronic disease • Chronic disease can lead to cardiovascular disease and is associated with significant healthcare burden • Nutrition interventions during recovery may prevent or minimize the onset of chronic illness, improving resource allocation
  158. 158. TREATMENT INDUSTRY LEADERS • Florida Recovery Center (FL) • Hazelden (MN) • Betty Ford (CA) • Treatment models that include measures to prevent post-detoxification overeating • Provide patients with access to dietitians • Emphasize exercise • Help patients to plan for expected changes in eating and the reinforcing effects of food
  159. 159. “Food for thought is no substitute for the real thing.” ~ Walt Kelly
  160. 160. SOME RULES TO LIVE BY… • Come back to earth • Choose least processed forms of food! • Eat a rainbow often • Wide variety of fruits and vegetables! • Choose lean protein • The fewer the legs the better! • Eat breakfast everyday • Start your day off right! • Aim for all 3 nutrients (carb/pro/fat) every 3 hrs • “Never hungry, never full” • Stay hydrated with water!
  161. 161. SOME RULES TO LIVE BY… • Make reductions in refined grains, sugar/salt/fat, caffeine/nicotine GRADUALLY yet PROGRESSIVELY • “Cold Turkey” can lead to problems (for some people) • Bring a sack lunch to work (or to wherever!) • Spend the extra time shopping and preparing food for yourself as a way of demonstrating self-care • Stay away from convenience stores and vending machines • Go to restaurants less often • Order with no added salt or oil • Ask for all dressings and sauces on the side • To RDNs: Be a good example of a healthcare professional 
  162. 162. SOMETIMES… It’s less about what you are eating… And more about what’s eating you… What’s eating you? Are you willing to believe things could be different?
  164. 164. It Is Not Enough To Stare Up The Steps; We Must Step Up The Stairs
  165. 165. QUESTIONS?