Definitions/Abbreviations
- Tardive dyskinesia: a neurological disorder characterized by involuntary movements of the face and jaw
- SSRI: Selective serotonin reuptake inhibitor– a class of drugs typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders
- Somatization Disorder: somatization is the physical manifestation of stress – a mental disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms (e.g. pain, neurologic problems, gastrointestinal complaints, and sexual symptoms) – the symptoms may or may not be traceable to a physical cause including general medical conditions, other mental illnesses, or substance abuse – regardless, symptoms cause excessive and disproportionate levels of distress
- Bipolar Disorder: “manic-depressive illness” – a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks – four basic types of bipolar disorder, all include clear changes in mood, energy, and activity levels – moods range from periods of extremely “up”, elated, and energized behavior (“manic episodes”) to very sad, “down”, or hopeless periods (“depressive episodes”) – hypomanic episodes are the less severe manic periods
- Munchhausen Syndrome: a psychological disorder characterized by the feigning of the symptoms of a disease or injury in order to undergo diagnostic tests, hospitalization, or medical or surgical treatment
- Malingering: exaggerating or feigning illness in order to escape duty or work
Pathophysiology
Describe the clinical symptoms which are manifested by patients with anorexia nervosa. How do these differ from the clinical symptoms of patients with bulimia? What criteria are used to diagnose anorexia nervosa, bulimia and EDNOS?
Anorexia nervosa (AN) is an eating disorder (a psychiatric condition) characterized by the refusal to maintain a minimally healthy body weight for age and height, usually through severe calorie restriction (self-starvation), an intense fear of gaining weight or becoming fat, and distorted perception of body shape and/or size, which can become so severe that even when emaciated they see themselves as fat, and amenorrhea in menstruating females. In addition to severely restricting the amount of food they eat, people with anorexia may also control calorie intake by vomiting after eating, and/or misusing laxatives, diet aids, diuretics or enemas, and excessive exercise is commonly used to prevent weight gain or continue losing weight. Bulimia nervosa (BN) is an eating disorder characterized by repeated episodes of binging (eating large amounts of food with a loss of control) and purging (trying to get rid of the extra calories in an unhealthy way). Purging behaviors used after binging to get rid of the extra calories and prevent weight gain include self-induced vomiting, fasting, strict dieting, excessive exercise, or the misuse of laxatives, weight-loss supplements, diuretics or enemas. The biggest difference between the clinical symptoms of these eating disorders is body weight – patients with AN are significantly underweight, while patients with BN usually have a body weight within normal limits.
Anorexia nervosa, bulimia, and EDNOS are diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
Describe the clinical symptoms of depression. How might diet impact the neurophysiological factors associated with this disorder?
Depression is a mood disorder characterized by a persistent feeling of sadness and loss of interest. Other clinical symptoms of depression include a feeling of hopelessness, poor appetite and weight loss, insomnia or disturbed sleep, restlessness or fatigue, thoughts of worthlessness and guilt, trouble concentrating or making decisions, and/or thoughts of death or suicide. Research has shown that individuals who follow a healthy diet, such as the Mediterranean diet, have a lower risk for developing depression, while those that have unhealthy eating habits (consume a lot of processed foods, high-fat products, and refined grains; low intake of fruits and vegetables) have a higher risk for developing depression.
Describe the most common clinical symptoms of a patient with Bipolar disorder. How might these impact nutritional intake?
Bipolar disorder is a mental health condition characterized by extreme mood swings that include periods of mania or hypomania (emotional highs) and depression (emotional lows). During the manic phase, common symptoms are restlessness, feeling euphoric, being full of energy or unusually irritable, needing little sleep, partaking in risky behavior and making poor decisions (e.g., unprotected sex with strangers, recreation drug use, spending more money than they can afford), and/or talking nonstop. Individuals in the depressive phase may feel sad or hopeless, lose interest or pleasure in most activities, have little energy, sleep too much or have trouble sleeping, become forgetful, have suicidal thoughts, and/or eat too much or too little.
During a manic episode, patients usually have increased energy needs due to a dramatic increase in activity levels. Since they are more likely to partake in risky behavior and make poor decisions during this phase, patients may consume an excess of unhealthy “feel-good” foods such as soda, candy, cakes, and other high sugar foods, and less nutritious foods. During a depressive episode, significant changes in appetite are common so food intake may be too much or too little, which can result in frequent weight fluctuations.
Drug Therapy
For each of the following classifications of drugs provide: indication/contraindication for use, nutrient/ drug interactions, side effects of the drug. The answer to this question may be provided in chart form. Note that examples of specific drugs that fall within each classification are provided.
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Drug Classification |
Indication for Use | Contraindication for Use | Nutrient/Drug Interactions |
Side Effects of the Drug |
Neuroleptic
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Mainly used in the treatment of schizophrenia and bipolar disorder
Also used to manage psychosis, including:
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Patient taking medications with similar side effects | Do not take with alcohol | Common side effects:
May also cause:
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TCA (tricyclic antidepressants)
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Depression | Patient taking:
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Common side effects:
May also cause:
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Stimulants
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Most often used to treat attention-deficit hyperactivity disorder (ADHD)
Can also help manage symptoms of:
|
|
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Common side effects:
May also cause:
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Alcohol Deterrent
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Alcohol dependence | Antabuse:
Naltrexone:
|
|
Common side effects:
May also cause:
In rare cases:
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Discuss the use of lithium therapy. Include indications/contraindications for use, its effect on sodium balance in relation to dietary implications, and possible complications associated with its use.
Lithium therapy helps to stabilize a person’s mood by acting on the central nervous system (the exact mechanism is unknown) and is used to treat bipolar disorder. Lithium is used to reduce the severity and frequency of manic episodes, and to help relieve or prevent bipolar depression. By stabilizing a patients’ mood, lithium can help prevent future manic and depressive episodes. Contraindications for lithium therapy include significant renal or cardiovascular disease, severe debilitation or dehydration, or sodium depletion. Patients taking antidepressant drugs, monoamine oxidase inhibitors, or receiving diuretics should also not use lithium.
Lithium alters sodium transport in nerve and muscle cells and can cause hyponatremia (low blood sodium levels). Hyponatremia can lead to elevated serum levels of lithium, which can eventually become toxic. This may be a problem for someone following a low sodium diet, such as the DASH diet. Dehydration can also lead to high levels of lithium, so patients taking lithium need to drink plenty of fluids and maintain a diet with normal sodium levels. For sodium, the goal is to keep daily consumption consistent to avoid any drastic fluctuations in blood levels of sodium.
Possible complications associated with lithium use include hand tremors, polyuria, increased thirst, nausea, diarrhea, vomiting, weight gain, impaired memory, muscle weakness, poor concentration, hair loss, drowsiness, acne, decreased thyroid function, and general discomfort during treatment.
Nutritional Management
What are the nutritional considerations in the management of a patient with major depression?
Significant changes in weight (gain or loss) and nutritional deficiencies must be monitored when managing a patient with major depression. Appetite changes are a common side effect of major depression, so it is important to monitor the patient for any significant changes in weight, work with them to develop strategies for preventing major weight fluctuations and provide educate about foods that may help alleviate symptoms of depression. There is a significant amount of research showing that nutritional interventions are useful in the treatment of depression. Increased consumption of omega-3 fatty acids (either from the diet or supplementation) have been shown to help reduce depressive symptoms. Low levels of vitamin B12, vitamin B6, and folate have been found to increase the risk of depression – levels of these vitamins are typically lower in depressed patients – so increasing consumption of foods rich in vitamin B or taking a vitamin B supplement can help combat depression. Decreased vitamin D levels are also common, so increased intake of foods fortified with vitamin D or a supplement may help but getting more sun exposure is the best way to increase vitamin D levels. This is because in addition to increasing vitamin D levels, spending more time outdoors can also lead to an improved mood, and relieve symptoms of depression. Serotonin deficiency has also been found to play a role in depression, so including high-quality protein foods rich in tryptophan is important in the management of depression. It is important to avoid caffeine, alcohol, and refined foods. Caffeine and alcohol may worsen symptoms of depression by reducing serotonin levels and increasing anxiety. Blood sugar balance is directly related to mood, so the more uneven your blood sugar supply is the more uneven your mood. Consuming foods high in sugar and refined carbohydrates causes an immediate spike in blood sugar, followed by a crash, which can cause an increase in mood swings or energy swings.
Discuss the effects of alcohol abuse on a patient’s nutritional status. What dietary recommendations would you give to an alcoholic patient?
Alcohol abuse can cause a patient to become malnourished. This is due to an imbalanced diet and/or anorexia, intestinal maldigestion and malabsorption, and increased excretion of selected vitamins. In patients with alcohol abuse, alcohol tends to replace food in the diet, and while alcohol is high in calories it offers little else (contains no protein, vitamins, or minerals). Since it is high in calories, it is possible to obtain maintenance energy needs from alcohol, but malnourishment often still occurs because it does not provide an adequate amount of nutrients. Another reason malnutrition occurs is that the liver preferentially metabolizes alcohol over whatever nutrients are obtained through food. Alcohol also interferes with the normal process of digestion and absorption by causing inflammation of the stomach, pancreas, and intestine, resulting in secondary malnutrition. During alcohol metabolism, excretion of certain vitamins is increased (particularly the B-vitamins and magnesium), resulting in increased needs.
When providing dietary recommendations to an alcoholic patient the primary objective is to spare the liver and provide it with the nutrients needed for regeneration. I would recommend a diet that provides 30-35 kcal/kg body weight, 1.5-2 g protein/kg body weight, 6-8 g of carbohydrates/kg body weight, and moderate fat. I would also recommend limiting sugar intake and following a regular meal schedule. Depending on the patient, a multivitamin and/or additional supplement may be necessary. If the patient is suffering from anorexia and cannot consume an adequate diet, then the initial focus will be on increasing dietary intake with foods, and I would recommend frequent small feedings which are usually better tolerated.
What are the nutritional goals for patients with anorexia nervosa? What are the nutritional goals for patients with bulimia nervosa? Describe methods for achieving successful food intake with these patients.
The primary nutritional goal for patients with anorexia nervosa is restoring their weight to at least 90% of the expected weight. During this nutritional repletion it is very important to monitor patients to make sure they do not develop refeeding syndrome. The patient’s goal weight can usually be achieved by normal oral feedings without having to administer nutrients enterally (via nasogastric tube), but in rare cases parenteral nutrition is needed. Other goals include cessation of weight loss behaviors, improvement in eating behaviors, and improvement in emotional and psychological health. In order to be successful, treatment plans need to allow sufficient time for weight gain and weight stabilization, as well as therapy to help the patient adjust emotionally to the healthier weight. Weight gain should be 2-3 lbs./week for inpatient treatment and 0.5-1 lb./week for outpatient treatment. Patient weigh-in protocols vary by program, but they usually address when patients are weighed, who weighs them, and whether or not patients are told their weight. To ensure successful food intake, meals should be supervised by staff members who firmly stress the importance of adequate food consumption, are empathic towards the patient, and provide encouragement and reassurance about their recovery.
The primary nutritional goal for patients with bulimia nervosa is to reduce the cycle of binging and purging and to normalize their eating habits. A common recommendation is for the patient to consume three meals and one to three snacks per day in a structured way, which can help provide order to eating and help break the cycle of binging and purging. A common trigger of binge eating is hunger, so initially food intake should be sufficient to prevent hunger. During this time, it is important to focus on helping the patient include a wider variety of foods in their diet, especially any foods they were forbidding themselves from eating. Patients may experience temporary fluid retention as their eating habits normalize, so it is important to provide education and support to help them deal with it. If the patient was laxative-dependent, it is important to provide education on preventing bowel obstruction during laxative withdrawal – consuming foods rich in dietary fiber and adequate amounts of fluid.
What diet recommendations have been given for children on the autism spectrum? What evidence is there to support these recommendations?
The gluten- and casein-free diet is a popular dietary intervention that claims to improve the symptoms of autism. People who advocate for this diet believe that those with autism have a leaky gut, which allows parts of gluten and casein to get into the bloodstream and affect the brain and central nervous system, causing autism or magnifying its symptoms. There are some studies that indicate this diet might be effective for some children, but it has not been proven by any controlled scientific studies. When implementing a restrictive diet such as this It is important to plan carefully and make sure all of the child’s nutritional needs are being met. Another dietary recommendation is to supplement with omega-3 fatty acids because it is an essential nutrient for brain development and proper neural function. Some studies have found evidence that supplementation results in improved behavior, mood, sleeping patterns, and focus, as well as spontaneous speech.
However, there is currently no research supporting any specific nutritional or dietary intervention for children on the autism spectrum. It is important to focus on the individual child and identify their specific behaviors affecting eating habits and food choices. Once you have identified the specific behaviors affecting the child’s eating habits and food choices, focus on developing strategies to overcome or work around these behaviors to ensure proper nutrition. For example, many children with autism are very picky eaters because they have sensitivities to certain tastes, colors, smells and textures, making it extremely difficult for parents or caregivers to provide a balanced diet. One of the best ways to address these sensory issues is to do it outside of the kitchen – you can bring the child to the supermarket with you and have them choose new foods, then do some research about it together when you get home (where it grows, nutrients it provides, the different ways to prepare it), and decide together how to prepare the food so the child knows what to expect. It doesn’t matter if they don’t end up eating the food, because by just becoming familiar with new foods in a positive-way that doesn’t put pressure on them can help them become open to trying to new foods in the future.
