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Nutrition in Recovery: The Role of the Dietitian in Addiction Treatment 2015

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David Wiss MS RDN discusses the importance of nutrition in addiction recovery and the rationale for the Registered Dietitian Nutritionist to be a member of the treatment team. Topics include:
Food and Mood
Food Addiction
Disordered Eating
Hormones
Nutrition Therapy

Published in: Health & Medicine
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Nutrition in Recovery: The Role of the Dietitian in Addiction Treatment 2015

  1. 1. Nutrition in Recovery: The Role of the Dietitian in Addiction Treatment
  2. 2. OBJECTIVES 1. Discuss the impact of addictive substances on nutritional status and links to chronic disease 2. Explore disordered and dysfunctional eating patterns in addicted populations 3. Propose nutrition therapy guidelines for specific substances and for poly-substance abuse
  3. 3. SECTIONS 1. Background 2. Food and Mood 3. Substance Use Disorders 4. Food Addiction 5. Disordered Eating 6. Hormones 7. Nutrition Therapy 8. Conclusions
  4. 4. 1. Background
  5. 5. BACKGROUND • Substance Use Disorders (SUDs) assoc. w/ vitamin & mineral deficiencies1-6 • What about altered neuro- circuitry? • Nutrition-related hormones? • Leptin, ghrelin, insulin • Gut microbiome? • We need to know more! 1. Estevez, J. F. D., Estevez, F. D., Calzadilla, C. H., Rodriquez, E. M. R., Romero, C. D., & Serra-Majem, 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, 449-455 2. Heathcote, J., & Taylor, K. B. (1981). Immunity and nutrition in heroin addicts. Drug and alcohol dependence, 8, 245-255. 3. 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/2/1/12 4. 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. 5. 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. 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.
  6. 6. NUTRITION AND DRUG ADDICTION • 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
  7. 7. 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
  8. 8. 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 coca- addicted populations may abolish addictive habit of coca chewing
  9. 9. 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.
  10. 10. 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
  11. 11. WHAT WE KNOW FOR SURE… • Individuals in recovery will benefit from learning new behaviors with respect to food & nutrition • Increasing body of evidence that suggests nutrition interventions in substance abuse treatment lead to improved outcomes1,2,3 Dysfunctional eating patterns and nutritional interventions in the SUD population require further investigation 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 2. Grant, L. P., Haughton, B., & Sachan, D. S. (2004). Nutrition education is positively associated with substance abuse treatment program outcomes. Journal of the American Dietetic Association, 104(4), 604-610. 3. Cowan, J. A., & Devine, C. M. (2012). Process evaluation of an environmental and educational intervention in residential drug- treatment facilities. Public Health Nutrition, 15, 1159-1167. doi:10.1017/S1368980012000572
  12. 12. TO BE CLEAR… • 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 • Given that weight gain following abstinence from drugs is a source of major personal suffering, there is a pressing need for a more detailed understanding of the effects of drug addiction on dietary intake 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
  13. 13. 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.
  14. 14. 2. Food and Mood
  15. 15. NUTRITION & MENTAL HEALTH Neurotransmitters Amino Acids Psych Meds? Cell Membranes Phospholipid Bilayer – EFAs
  16. 16. 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
  17. 17. 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.
  18. 18. 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.
  19. 19. 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.
  20. 20. DOPAMINE • Catecholamine neurotransmitter • Dopamine is the major brain chemical involved in addiction • Important in: • Movement (muscle control) • Motivation and attention • Reward • Well-being
  21. 21. FOOD & MOOD – Protein • Tyrosine
  22. 22. FOOD & MOOD – Protein • Dopamine and norepinephrine are often associated with alcohol / drug abuse Low dopamine associated with drug abuse…(receptor dysfunction) What can mimic the reward one gets from drug use?
  23. 23. 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.
  24. 24. 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 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
  25. 25. ADDICTION & MENTAL HEALTH • Addictive substances strip brain of essential fats, and impair absorption/utilization of AA’s necessary for neurotransmitter synthesis1 • Controlled studies have linked essential fatty acid deficiency to anxiety as well as relapse2,3 • ***Nutrient deficiencies/imbalances may cause behavior resembling dual diagnosis 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 chemical dependent patients, and reduce prescriptive care contraindicated in the condition of substance abuse.”4 1. Grotzkyj-Giorgi, M. (2009). Nutrition and addiction – can dietary changes assist with recovery?. Drugs and Alcohol Today, 9(2), 24-28. 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. 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, T. J. (2008). Nutritional links to substance abuse recovery. Journal of Addictions Nursing, 19, 125-129.
  26. 26. 3. Substance Use Disorders (SUDs)
  27. 27. 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.
  28. 28. 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
  29. 29. 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
  30. 30. POLY-SUBSTANCE ABUSE • Significantly low vit. A, C, E levels compared to non-addict controls1 • Antioxidant vitamins • Increased copper2,3 • Inflammation? • Increased zinc2 • Acute fasting? • Immune regulation? • Decrease in iron2,4 • Malnutrition? • Role of other lifestyle factors? 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 3. 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 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
  31. 31. 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
  32. 32. 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., & Serra- Majem, 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, 449- 455. doi:10.1038/sj.ejcn.1601827
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. STIMULANTS • Many ED patients gravitate towards their use (appetite suppression) • Daily users more likely to snack than eat meals • Post-using (“come down”) binge- eating behavior • Use again as compensatory purge • ED vs. SUD vs. Dual-Diagnosis
  37. 37. 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 BP than heroin or meth2 CKD or CVD 1. Janowsky, D. S., Pucilowski, O., & Buyinza, M. (2003). Preference for higher sucrose concentrations in cocaine abusing- dependent 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.
  38. 38. 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.
  39. 39. 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 n- acetylcysteine? American Journal of Psychiatry, 164(7), 1115-1117.
  40. 40. 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.
  41. 41. 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 street- recruited injecting drug users: Prevalence and correlates of problem. Addiction, 103, 1821- 1825. doi:10.1111/j.1360- 0443.2008.02339.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, 27- 37. doi:10.1111/j.1601- 0825.2008.01459.x
  42. 42. 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
  43. 43. METHAMPHETAMINE • Animal models: • Antioxidant Se plays protective role in meth- induced neurotoxicity1 • Co-Q10 shown to attenuate meth and cocaine neurotoxicity2 1. Imam, S. Z., & Ali, S. F. (2000). Selenium, an antioxidant, attenuates methamphetamine- induced 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, 303- 311. doi:10.1007/s11064-005-9025-3
  44. 44. 4. Food Addiction
  45. 45. “ADDICTION”* – DSM-5 • “Substance-Related and Addictive Disorders” • Alcohol-Related • Caffeine-Related • Cannabis-Related • Hallucinogen-Related • Inhalant-Related • Opioid-Related • Sedative-, Hypnotic, or Anxiolytic-Related • Stimulant-Related • Tobacco-Related • Non-Substance-Related Specify current severity: Mild (2-3 symptoms) Moderate (4-5 symptoms) Severe (6 or more symptoms) Specify descriptive features: In early remission In sustained remission On maintenance therapy In a controlled environment *The word “addiction” is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation
  46. 46. “ADDICTION” – DSM-5 • Non-Substance-Related • Gambling • Behavioral Addictions? • Sex Addiction • Exercise Addiction • Shopping Addiction Currently insufficient evidence for diagnostic criteria What about food??? Is it substance-related? Behavioral? Both?
  47. 47. ADDICTIVE SUBSTANCES • Alcohol/drugs • Nicotine • Caffeine • Food (for some people) • Refined grains • Refined sugar • Artificial sweeteners • Added salts • Added fats • Others???
  48. 48. “PROCESS ADDICTIONS” • Eating • Gambling • Shopping • Internet • Pornography • Sex • Crime • Others???
  49. 49. 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
  50. 50. 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.
  51. 51. 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 by- products of food? aka processed food?
  52. 52. COCA LEAF VS. CRACK COCAINE Coca Leaf • Not highly addictive Powder Cocaine • By-product • Addictive Crack Cocaine • Further processed • Wreaks havoc on human brain
  53. 53. POPPY PLANT VS. HEROIN Poppy Plant • Not highly addictive Raw opium • By-product • Addictive Heroin • Further processed • Highly Addictive
  54. 54. WHEAT PLANT VS. WHITE FLOUR Wheat Plant • Not addictive Whole Wheat Flour • By-product Refined White Flour • Further Processed • “Offensive”
  55. 55. CORN VS. HIGH FRUCTOSE CORN SYRUP (HFCS) Corn • Not addictive Corn Syrup • By-product HFCS • Further Processed • “Offensive”
  56. 56. FOOD ADDICTION • Drugs addicts share many characteristics with compulsive overeaters • Brain imaging1 • Behavioral2 • “Reward” from substance • Drugs/alcohol • Hedonic food • Highly palatable food • Processed food w/ added sugars/salt/fat 1. Volkow, N. D., & Wise, R. A. (2005). How can drug addiction help us to understand obesity? Nature Neuroscience, 8(5), 555-560. 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.
  57. 57. FOOD ADDICTION • Endogenous opioid release1 • Dopamine activity in brain2 • Gut-brain dopamine axis3 • Site of convergence • Metabolic/hormonal • Regulate eating behavior 1. Yeomans, M. R., & Gray, R. W. (2002). Opioid peptides and the control of human ingestive behaviour. Neuroscience and Biobehavioral Reviews, 26, 713-728. 2. Stice, E., Spoor, S., Bohon, C., & Small, D. M. (2008, October). Relation between obesity and blunted striatal response to food is moderated by TaqIA A1 allele. Science, 332, 449-452. 3. De Araujo, I. E., Ferreira, J. G., Tellez, L. A., Ren, X., & Yeckel, C. W. (2012). The gut-brain dopamine axis: A regulatory system for caloric intake. Physiology and Behavior, 106(3), 394-399.
  58. 58. 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. 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. 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.
  59. 59. 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 Reese’s peanut butter cups and crunchy heath bar pieces becomes irresistible
  60. 60. FOOD ADDICTION – CULPRITS Refined grains… w/ sugar/salt/fat
  61. 61. FOOD ADDICTION – CULPRITS What is the difference between a baked potato and French fries with ketchup? Fat…Salt…Sugar
  62. 62. Schulte, E. M., Avena, N. M., & Gearhardt, A. N. (2015). Which foods may be addictive? The roles of processing, fat content, and glycemic load. PLoS ONE, 10(2). 1. Chocolate 2. Ice Cream 3. French Fries 4. Pizza 5. Cookie 6. Cake 7. Popcorn (Buttered) 8. Cheeseburger
  63. 63. 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 at home (rehab) • 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”?
  64. 64. 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. 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.
  65. 65. 5. Disordered Eating
  66. 66. NUTRITION & ADDICTION TREATMENT • Disordered eating • Drug abuse risk factor for EDs1 • Genetic and environmental2 • Increased sugar use over time3 • Alcohol linked to bingeing/purging4 1. Krahn, D. D. (1991). The relationship of eating disorders and substance abuse. Journal of Substance Abuse, 3(2), 239-253. 2. Munn-Chernoff, M. A., Duncan, A. E., Grant, J. D., Wade, T. D., Agrawal, A., Bucholz, K. K., ... Heath, A. C. (2013). A twin study of alcohol dependence, binge eating, and compensatory behaviors. Journal of Studies on Alcohol and Drugs, 74, 664-673. 3. Levine, A. S., Kotz, C. M., & Gosnell, B. A. (2003). Sugar and fats: The neurobiology of preference [Special section]. Journal of Nutrition, 831S-834S. 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.
  67. 67. 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
  68. 68. 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
  69. 69. 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 (psych meds?) 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
  70. 70. 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)
  71. 71. BULIMIA NERVOSA (BN) – DSM-5 A. Recurrent episodes of binge eating, characterized by: 1. Eating amount definitely larger than normal w/in 2-hour period 2. Sense of lack of control over eating during the episode B. Recurrent inappropriate compensatory behavior in order to prevent weight gain (vomiting, laxatives, diuretics, medications, fasting, exercise) C. Binge eating and compensatory behavior occur (on average) at least once a week for 3 months D. Self-evaluation is unduly influenced by body shape and weight E. The disturbance does not occur exclusively during episodes of anorexia nervosa
  72. 72. BINGE EATING DISORDER (BED) – DSM-5 A. Recurrent episodes of binge eating, characterized by: 1. Eating amount definitely larger than normal w/in 2-hour period 2. Sense of lack of control over eating during the episode B. Episode has 3 or more: 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts when not physically hungry 4. Eating alone because of embarrassment 5. Feeling disgusted/depressed/guilty C. Marked distress D. Occurrence of once per week for at least 3 months E. No compensatory behavior (i.e. “purge”)
  73. 73. BED vs. FOOD ADDICTION Binge Eating Disorder • Ate the whole box of chocolates in one sitting • Emotional disturbance • DSM-5 clinical diagnosis, insurance reimbursement Food Addiction • Ate the whole box over several sittings • Physiological response • Not recognized or reimbursable There are more similarities than there are differences… Obesity can exist without either one!
  74. 74. NOW AVAILABLE!!!
  75. 75. DISORDERED EATING IN MALES • More commonly in pursuit of a lean, muscular physique • Role of the fitness industry • Similar to the fashion industry • Unrealistic body types • Photoshop Body dissatisfaction
  76. 76. PHYSICAL APPEARANCE CONCERNS • Dissatisfied • Preoccupied • Impairment/distress • Insecure • Seeking reassurance • Disturbed self-perception
  77. 77. ED & SUD – MALES • Men w/ BED greater frequency of SUD1 • Many men uncover symptoms of EDs during addiction treatment2 (hiding out?) • SUD not limited to street drugs may include3 • Fat burners • Anabolic androgenic steroids • Performance-enhancing drugs 1. Barry, D. C., Grilo, C. M., & Masheb, R. M. (2002). Gender differences in patients with binge eating disorder. International Journal of Eating Disorders, 31, 63-70. 2. Stanford, S. C., & Lemberg, R. (2012). Measuring eating disorders in men: Development of the eating disorder assessment for men (EDAM). Eating Disorders: The Journal of Treatment and Prevention, 20(5), 427-436. 3. Eisenberg, M. E., Wall, M., & Neumark-Sztainer, D. (2012). Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics, 130(6), 1019-1026.
  78. 78. STEROIDS & SUD • 35% of male steroid abusers met lifetime criteria for SUD1 • Dependence syndromes • Progression to other recreational drugs, including stimulants2 • Significant percentage of male heroin addicts living in a treatment facility used opioids to counteract associated depression and withdrawal following steroid abuse3 1.Kanayama, G., Hudson, J. I., & Pope Jr., H. G. (2008). Long-term psychiatric and medical consequences of anabolic- androgenic steroid abuse. Drug and Alcohol Dependence, 98(1-2), 1-12. 2. Hildebrandt, T., Langenbucher, J. W., Lai, J. K., Loeb, K. L., & Hollander, E. (2011). Development and validation of the appearance and performance enhancing drug schedule. Addictive Behavior, 36(10), 949-958. 3. Arvary, D. & Pope Jr., H. G. (2000). Anabolic-androgenic steroids as a gateway to opioid dependence. New England Journal of Medicine, 342(20), 1532.
  79. 79. EXERCISE DEPENDENCE • Describing the related phenomenon of compulsive physical activity1 • Originally did not involve muscle development, only aerobic • Now linked to drive for muscularity2 • May partially explain the phenomenon of steroid addiction 1. Veale, D. (1987). Exercise dependence. British Journal of Addiction, 82, 735-40. 2. Hale, B. D., Roth, A. D., DeLong, R. E., & Briggs, M. S. (2010). Exercise dependence and the drive for muscularity in male bodybuilders, power lifters, and fitness lifters. Body Image, 7, 234-239.
  80. 80. 6. Hormones
  81. 81. APPETITE HORMONES • Leptin (produced by adipose tissue, signals brain to stop eating) • Ghrelin (produced in stomach, hunger- hypothalamus) • Insulin (regulates food intake) • Norepinephrine (fight or flight) • Cortisol (steroid hormone in response to stress, physiological antagonist to insulin) • Peptide YY (induces satiety)
  82. 82. VENTRAL TEGMENTAL AREA (VTA) • Contains dopamine neurons that project to cortico-limbic structures: • Nucleus accumbens (pleasure) • Medial prefrontal cortex (cognition) • Hippocampus (memory) • Amygdala (emotional reactivity) • Direct input from hypothalamus • Governs several endocrine processes (leptin, ghrelin)
  83. 83. FACTORS THAT REGULATE FOOD INTAKE • Caloric requirements • Reinforcing responses • Palatability • Conditioned responses • Cues • Cognitive control • Inhibition/regulation
  84. 84. WHY PEOPLE LIKE JUNK FOOD • Stomach as 2nd Taste System • “Sensing receptors” • Mechanoreceptors • Chemoreceptors • Thermoreceptors • Osmoreceptors • Wall of gut brain stem • Neurohormonal stimuli • Ghrelin (appetite stimulant) • “Light” versions of food detected by Gut-Brain Axis Witherly, S. A. (2007). Why humans like junk food. Lincoln, NE: iUniverse
  85. 85. LEPTIN • Produced/secreted by adipose tissue • Plasma leptin associated w/ fat mass • Increases metabolic rate • Initiates starvation response • Decreases food intake • Reward value of sucrose decreased by leptin via reduction in dopamine signaling1 1. De Araujo, I. E., Deisseroth, K., Domingos, A. I., Friedman, J., Gradinaru, V., & Ren, X. (2011). Leptin regulates the reward value of nutrient. Nature Neuroscience, 14, 1562-1568.
  86. 86. LEPTIN • Low levels lead to higher reward value of food • Body perceives hungry state, enhancing motivation for food • When satiated, dopamine release/firing inhibited in nucleus accumbens • Interestingly… • High levels have no pronounced effect on metabolism/feeding1 1. Pandit, R., de Jong, J. W., Vanderschuren, L. J. M. J., & Adan, R. A. H (2011). Neurobiology of overeating and obesity: The role of melanocortins and beyond. European Journal of Pharmacology, 660, 28-42.
  87. 87. LEPTIN & VTA • Leptin regulates homeostatic center of hypothalamus • Hedonic system1 • Subjective desires for food • Food deprivation decreases circulating leptin • Contributing to preference for highly palatable foods • Leptin-dopamine interaction • Bi-directional2 1. Schloegl, H., Percik, R., Hortsmann, A., Villringer, A., & Stumvoll, M. (2011). Peptide hormones regulating appetite - focus on neuroimaging studies in humans. Diabetes/Metabolism Research and Reviews, 27, 104-112. 2. Leinninger, G. M. (2011). Lateral thinking about leptin: A review of leptin action via the lateral hypothalamus. Physiology and Behavior, 104(4),
  88. 88. GHRELIN • Stimulates appetite • Decreases after eating • Opposing effects with leptin • Leptin counters ghrelin • Stomach-derived • Receptors identified in VTA, hippocampus, amygdala1 • Sight of food elevates ghrelin2 • Non-obese healthy subjects 1. Dagher, A (2012). Hunger, hunger, and food addiction. In Brownell, K. D., & Gold, M. S., Food and addiction (131-137). New York, NY: Oxford University Press. 2. Schussler, P., Kluge, M., Yassouridis, A., Dresler, M., Uhr, M., & Steiger, A. (2012). Ghrelin levels increases after pictures showing food. Obesity, 20, 1212-1217.
  89. 89. GHRELIN & VTA • Obese subjects1 • Ghrelin low • Post-meal ghrelin remains higher • Injection of ghrelin into VTA and nucleus accumbens increases feeding behavior2 • VTA direct target site for ghrelin’s action on sweet food motivation3 • Enhanced intake of saccharin4 1. English, P. J., Ghatei, M. A., Malik, I. A., Bloom, S. R., & Wilding, J. P. H. (2002). Food fails to suppress ghrelin levels in obese humans. The Journal of Clinical Endocrinology and Metabolism, 87(6), 2984-2987. 2. Naleid, A. M., Grace, M. K., Cummings, D. E., & Levine, A. S. (2005). Ghrelin induces feeding in the mesolimbic reward pathways between the ventral tegmental area and the nucleus accumbens. Peptides, 26, 2274-2279. 3. Skibicka, K. P., Hansson, C., Alvarez- Crespo, M., Friberg, P. A., & Dickson, S. L. (2011). Ghrelin directly targets the ventral tegmental area to increase food motivation. Neuroscience, 180, 129-137. 4. Disse, E., Bussier, A., Veyray-Durebex, C., Deblon, N., Pfluger, P. T., Tschop, M. H., ...Rohner-Jeanrenaud, F. (2010). Peripheral ghrelin enhances sweet taste food consumption and preference, regardless of its caloric content. Physiology and Behavior, 101, 277-281.
  90. 90. GHRELIN & VTA • Ghrelin alters set point of dopaminergic neurons1 • Anticipatory physiological responses to scheduled meals2 • Opioid receptor pathways3 • Regulation of food incentive and hedonics • Motivational effects on feeding4 1. Dickson, S. L., Egecioglu, E., Landgren S., Skibicka, K. P., Engel, J. A., & Jerlhag (2011). The role of central ghrelin system in reward from food and chemical drugs. Molecular and Cellular Endocrinology, 340, 80-87. 2. Pandit, R., Mercer, J. G., Overduin, J., la Fleur, S. E., & Adan, R. A. H. (2012). Dietary factors affect food reward and motivation to eat. Obesity Facts, 5, 221-242. 3. Kawahara, Y., Kaneko, F., Yamada, M., Kishikawa, Y., Kawahara, H., & Nishi, A. (2013). Food reward-sensitive interaction of ghrelin and opioid receptor pathways in mesolimbic dopamine system. Neuropharmacology, 67, 395-402. 4. Overduin, J., Figlewicz, D. P., Bennet-Jay, J., Kittleson, S., & Cummings, D. E. (2012). Ghrelin increases motivation to eat, but does not alter food palatability. The American Journal of Physiology - Regulatory, Integrative and Comparative Physiology, 303, R259-R269.
  91. 91. INSULIN • Peptide hormone from pancreas • Similarities to leptin: • Adiposity signal • Anorexigenic • Attenuates food reward • When low, drive for food intake increases • Works with dopamine to calibrate reward associated with feeding1 • Depresses dopamine conc. in VTA, which may suppress salience of food once satiety is reached 1. Mebel, D. M., Wong, J. C. Y., Dong, Y. J., & Borgland, S. L. (2012). Insulin in the ventral tegmental area reduces hedonic feeding and suppresses dopamine concentration via increased reuptake. Behavioral Neuroscience, 36, 2336-2346.
  92. 92. INSULIN & LEPTIN • Insulin receptor signaling pathway interferes with leptin signaling • Insulin blocks leptin • Hyperinsulinemia contributes to the pathogenesis of leptin resistance1 • Interferes with leptin extinguishing of dopamine clearance in the nucleus accumbens2 (addiction) 1. Kellerer, M., Lammers, R., Fritsche, A., Strack, V., Machicao, F., Borboni, P., Ullrich, A., & Haring, H. U. (2001). Insulin inhibits leptin receptor signaling in HEK293 cells at the level of janus kinase-2: A potential mechanism for hyperinsulinaemia-associated leptin resistance. Diabetologia, 44, 1125-1132. 2. Lustig, R. H. (2013, October). Sugar, hormones and addiction. Symposium conducted at The Lifestyle Intervention Conference, Las Vegas, NV.
  93. 93. INSULIN & GHRELIN • Similar to ghrelin, receptors in1 • Hypothalamus • VTA • Hippocampus • Amygdala • Secretion decreased by ghrelin2 • Vice versa3 1. Dagher, A (2012). Hunger, hunger, and food addiction. In Brownell, K. D., & Gold, M. S., Food and addiction (131-137). New York, NY: Oxford University Press. 2. Broglio, F., Arvat, E., Benso, A., Gottero, C., Mucciolo, G., Papotti, M., ... Ghigo, E. (2001). Ghrelin, a natural GH secretatogue produced by the stomach, induces hyperglycemia and reduces insulin secretion in humans. The Journal of Clinical Endocrinology and Metabolism, 86(10), 5083-5086. 3. Broglio, F., Gottero, C., Prodam, F., Destesfanis, S., Gauna, C., Me, E., ... Ghigo, E. (2004). Ghrelin secretion is inhibited by glucose load and insulin-induced hypoglycaemia but unaffected by glucagon and arginine in humans. Clinical Endocrinology, 61, 503-509.
  94. 94. Daws, L. C., Avison, M. J., Robertson, S. D., Niswender, K. D., Galli, A., & Saunders, C. (2011). Insulin signaling and addiction. Neuropharmacology, 61(7), 1123-1128. • Insulin-influenced dopamine transmission can affect the ability of drugs to exert their neurochemical and behavioral effects • Insulin receptors present in brain and midbrain dopamine neurons • Interplay between insulin signaling and drug-induced increases in extracellular dopamine may contribute to high comorbidity of eating disorders and drug abuse • Improvements in brain dopamine function by normalizing or bypassing disruptions in insulin signaling might be effective in treating addictions
  95. 95. ALCOHOL & GHRELIN • Rewarding properties of alcohol require ghrelin1 • Ghrelin increases during withdrawal2 (changes in hunger?) • Alcoholic beverage before a meal? (stimulates appetite) • Key role in alcohol-seeking behavior3 • Dopamine neurobiology • Hyperghrelinemia related to addiction?1 Innovative treatment?3 1. Jerlhag, E., Egecloglu, E., Landgren, S., Salome, N., Hellg, M., Moechars, D., ... Engel, J. A. (2009). Requirement of central ghrelin signaling for alcohol reward. Proceedings of the National Academy of Sciences, 106(27), 11318-11323. 2. Kraus, T., Reulbach, U., Bayerlein, K., Mugele, B., Hillemacher, T., Sperling, W., ... Bleich, S. (2004). Leptin is associated with craving in females with alcoholism. Addiction Biology, 9, 213-219. 3. Leggio, L., Ferrulli, A., Cardone, S., Nesci, A., Miceli, A., Malandrino, N., ... Addolorato, G. (2011). Ghrelin system in alcohol-dependent subjects: Role of plasma ghrelin levels in alcohol drinking and craving. Addiction Biology, 17, 452-464.
  96. 96. METHAMPHETAMINE • Linked to eating disorders1 • Food restriction enhances rewarding effect2 • Ghrelin required for reward3 • Hyperghrelinemia observable in SUD patients raises important questions about ghrelin + meth3 1. Neale, A., Abraham, S., & Russell, J. (2008). "Ice" use and eating disorders: A report of three cases. International Journal of Eating Disorders, 42, 188-191. 2. Cabeza de Vaca, S., & Carr, K. D. (1998). Food restriction enhances the central rewarding effect of abused drugs. The Journal of Neuroscience, 18(8), 7502-7510. 3. Jerlhag, E., Egecioglu, E., Dickson, S. L., & Engel, J. A. (2010). Ghrelin receptor antagonism attenuates cocaine- and amphetamine-induced locomotor stimulation, accumbal dopamine release, and conditioned place preference. Psychopharmacology, 211, 415-422.
  97. 97. COCAINE • PET brain imaging: deficits in dopamine signaling similar for cocaine-addicted and obese rats1 • Human addicts prefer highest preference of sucrose offered2 • Reinforces depleted reward pathways 1. Michaelides, M., Thanos, P. K., Kim, R., Cho, J., Ananth, M., Wang, G., & Volkow, N. D. (2012). PET imaging predicts future body weight and cocaine preference. Neuroimage, 59, 1508-1513. 2. Levandowski, M. T., Viola, T. W., Tractenberg, S. G., Teixeira, A. L., Brietzke, E., Bauer, M. E., & Grassi-Oliveira, R. (2013). Adipokines during early abstinence of crack cocaine in dependent women reporting childhood maltreatment. Psychiatry Research, 210, 536-540.
  98. 98. COCAINE • Ghrelin modulates reinforcement and reward1 • Female crack users2 • Low leptin in early abstinence • Increasing during detoxification • Improved diet, weight gain 1. Clifford, P. S., Rodriguez, J., Schul, D., Hughes, S., Kniffin, T., Hart, N., ... Martinez, J. (2012). Attenuation of cocaine-induced locomotor sensitization in rats sustaining genetic or pharmacologic antagonism of ghrelin receptors. Addiction Biology, 17(6), 956-963. 2. Michaelides, M., Thanos, P. K., Kim, R., Cho, J., Ananth, M., Wang, G., & Volkow, N. D. (2012). PET imaging predicts future body weight and cocaine preference. Neuroimage, 59, 1508-1513.
  99. 99. 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
  100. 100. OPIATES • Ghrelin likely more responsible than leptin for inducing increases in drug-taking and drug-seeking behaviors1 • However, treatment with a ghrelin receptor agonist had no effect on reinstatement of heroin-seeking in rats1 1. Maric, T., Sedki, F., Ronfard, B., Chafetz, D., Shalev, U. (2012). A limited role for ghrelin in heroin self-administration and food deprivation-induced reinstatement of heroin seeking in rats. Addiction Biology, 17(3), 613- 622.
  101. 101. 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.
  102. 102. HORMONES – DISCUSSION • Food and drugs compete for overlapping reward mechanisms • When substance abstinence has been achieved, likely a compensatory increased drive for food • Ravenous “rebound appetite” • Hypothalamus
  103. 103. HORMONES – DISCUSSION • Normalizing disrupted leptin signaling cascade may be sufficient to decrease motivation for food reward • Weight gain during addiction recovery should be monitored/controlled in order to counter associated hormonal adaptions • Exposure to highly palatable
  104. 104. 7. Nutrition Therapy
  105. 105. “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.
  106. 106. CAFFEINE • No longer just coffee, tea, chocolate and sodas • Energy drinks, pills • Workout supplements (>300mg) • “Caffeinism” 600-750 mg/day • >1000 mg/day defined as toxic1 • DSM-5: >250 mg can be intoxicating • 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
  107. 107. NICOTINE Nicotine • 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 Introducing the e-cig? 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.
  108. 108. “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
  109. 109. 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
  110. 110. 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
  111. 111. 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
  112. 112. NUTRITION INTERVENTIONS – GOALS • Primary goal is to support recovery by any means necessary • Complete abstinence from all mind- altering substances • Nutrition therapy emphasizing correction of nutrient deficiencies • Lab data to warrant aggressive interventions
  113. 113. 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!
  114. 114. 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
  115. 115. 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
  116. 116. 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
  117. 117. EATING REGULARLY • Provides the body with continuous supply of energy • Eat every 2-4 hours • Stabilize energy levels, stable BG • Avoid the “crash” by limiting sugar, refined grains, and caffeine • Prevent cravings for sweets • Prevent cravings for alcohol/drugs
  118. 118. 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
  119. 119. 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
  120. 120. RECS – OPIATES • Liquid MVI (low metal) • Additional vit. B6 • Additional calcium and vit. D • Digestive enzymes, probiotics • Fiber if constipated (Chia!) • Higher caloric needs? • Diet rich in vits A, C, E, Se, Fe
  121. 121. 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 cocaine- dependent men. Appetite. Advance online publication. Retrieved from http://dx.doi.org/10.1016/j.appet.2013 .07.011
  122. 122. 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
  123. 123. 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 • Gut bacteria • Beans, nuts, seeds! • Brazil nuts (Se) 1. Hoffinger, R. (2012). The recovery diet. Avon, MA: Adams Media.
  124. 124. 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
  125. 125. 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
  126. 126. 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
  127. 127. IS DIETARY COUNSELING ENOUGH?
  128. 128. THE EIGHT DIMENSIONS OF WELLNESS
  129. 129. 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 alcohol- ten 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 • NORMALIZE HORMONES 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.
  130. 130. BIG PICTURE – GOALS • Not necessarily weight loss • Relapse prevention • Disease prevention • Focus on overall health • Body, mind, spirit • Behavior change & self-efficacy • “Sanity restoration” • “Recovery” • Can be difficult to measure Eventually developing a relationship w/ food & exercise that is intuitive/personal • Avoid “quick fix” whenever possible
  131. 131. 8. Conclusions
  132. 132. CONCLUSIONS • Restoration of nutritional status in SUD should look beyond vitamin/mineral status and body weight! • Goals should include: • Gut (HOT TOPIC) • Brain chemistry • Hormones Minimize spikes/drops in insulin Normalize leptin, prevent hyperghrelinemia
  133. 133. THE ROLE OF THE DIETITIAN • Dietary intake • Nutritional needs • Regular feeding patterns • Healthy weight goal • Food fears, restrictions, rules • Feelings/emotions around food • Medical nutrition therapy
  134. 134. 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 (Nutrition Therapy) • Collect data and publish findings (that means YOU!) • Develop curriculum • 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”
  135. 135. 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
  136. 136. BREATHE LIFE HEALING CENTERS • RDN integrated member of the treatment team! • Individual counseling • Educational groups • Approves all food/beverage • Meal/snack planning • Supermarket tours • Meal outings
  137. 137. BIODYNAMIC URBAN FARM @ BREATHE
  138. 138. RECOVERY IS POSSIBLE!
  139. 139. “Food for thought is no substitute for the real thing.” ~ Walt Kelly
  140. 140. It Is Not Enough To Stare Up The Steps; We Must Step Up The Stairs
  141. 141. QUESTIONS?

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