Behavioral Health Nutrition

By Alexis Mateer

How does substance use disorder relate to nutrition and dietetics? This is the question that I was pondering when walking into Pathways treatment center one recent Tuesday morning. I was in the middle of my eight week clinical rotation at Anne Arundel Medical Center (AAMC), a small community hospital in Annapolis, MD. Pathways, a not-for-profit drug and alcohol rehabilitation treatment facility, is located separate from the main hospital, but is still part of AAMC. Pathways has one dietitian and I was lucky enough to get to spend four days observing and learning from her. Substance use disorder (SUD) and its nutritional implications are not something that I learned about in my undergraduate medical nutrition therapy classes. I started my week feeling intrigued and excited.

Little did I know, there is a thriving, growing knowledge base and workforce of dietitians that dedicate entire careers to working with individuals struggling with SUD. My wonderful preceptor at Pathways, Lise, told me that nutritional care for patients with SUD falls under a practice term known as behavioral health nutrition (BHN). There is a dietetic practice group (DPG) within the Academy of Nutrition and Dietetics packed full of dedicated nutrition professionals working within behavioral health care. BHN is a DPG that Academy members can join in order to become connected to resources, practice tips, research, and other like-minded professionals. Lise also instructed me that Pathways is a treatment facility that is dedicated specifically to those struggling with SUD. Patients with comorbid eating disorders and/or serious mental health issues are not treated at Pathways. However, there are facilities that exist for people with SUD and comorbid eating disorders.

On my first day at Pathways, I toured the new kitchen. 

So What is Behavioral Health Nutrition?

On day one, in addition to going with my preceptor to visit patients in the treatment facility, Lise sat me down and took the time to explain what BHN encompasses. There are three main tracks, or focuses, within BHN: eating disorders, substance use disorder, and mental health. These are three separate focuses, or areas of practice, when it comes to nutrition. However, these also are issues that can overlap within one individual- issues with which one person can struggle. For example, there are people that struggle with eating disorders, people that struggle with substance abuse, and people that struggle with both. So while these two might be separate focuses, or specialties, within the nutrition world, they are certainly not always separate entities or issues in the real world. While this was all very important, relevant information, I still found myself asking the same question as before. How does substance use disorder, and behavioral health more broadly, relate to nutrition and dietetics? Here is what I learned:

Pertinent Nutritional Issues in BHN

  1. Malnutrition – This has to be the largest nutritional issue facing individuals struggling with SUD. Lise told me that people struggling with SUD often prioritize accessing their substance(s) of choice, before getting food. It is clear how protein-energy malnutrition could be an issue, but micronutrient malnutrition is also prominent in this population. Deficiencies of certain vitamins and minerals more commonly present in individuals struggling with SUD than in the general population. Because of this, my preceptor stressed the importance of the nutrition focused physical exam (NFPE). Knowing how micronutrient deficiencies present, and what to look for is a vital skill when working in this setting. I did not get to conduct a NFPE while at Pathways, but I did get information about what some micronutrient deficiencies look like, and which ones are most pertinent, or common, in this setting. The Color Atlas of Nutritional Disorders pictured below is a great resource for learning about the physical presentation of malnutrition and related nutrient deficiencies.
  2. Wounds – I saw a patient with a wound caused by repeated injections into the same site. Wound healing requires micronutrients like vitamin C and zinc, and some people struggling with SUD are deficient in these nutrients.
  3. Diabetes – It is important to remember that patients with SUD often struggle with common medical conditions in addition to their addiction(s). Diabetes is becoming more common in the US, and people struggling with SUD are no exception. I learned that in patients with SUD, diabetes is typically very poorly controlled. This is not surprising since, as I noted earlier, eating meals is not always a priority. Besides the macrovascular disease that occurs over a lifetime of poorly controlled diabetes, extreme highs and lows in blood sugar might be more common in those struggling with SUD, posing a very serious health risk.

A few of the resources from Lise related to behavioral health nutrition.

Activities During my Week at Pathways

On day one, Lise spent a great deal of time talking with me about BHN, exploring the BHN DPG webpage, and discussing nutritional challenges and issues individuals with SUD face. I also got a tour of the facility, including the new kitchen pictured above, and got to sit in on my first, daily team huddle. The daily huddle is an interdisciplinary team meeting, including doctors, nurses, case workers, therapists, and Lise, the dietitian. This team meets every morning, for 30 minutes to 1 hour, to discuss each patient and his/her progress, with each discipline offering pertinent info or findings to the rest of the team. It is a way for each team member to be debriefed on patients’ progress. I got to attend this meeting each morning with Lise, all-the-while learning more about what different disciplines bring to the table in a treatment facility of this nature. Throughout these four days I also got to go see some patients with Lise. She would first look into the patient’s chart, and then go out into the facility to find the patient. At Pathways the patients’ days are scheduled full with activities, so Lise would have to go search for the patient in their groups, the common areas, or even in the cafeteria during meal times. This is very different from how dietitians in the hospital meet with patients; at pathways the patients are rarely in their assigned rooms. Lise would follow up with the patient about his/her progress, provide further nutrition education and support, especially for those patients with diabetes, answer questions, and make recommendations for patients to consume more of certain foods and/or offer supplements. For example, for a patient we saw that had a large, open wound on his hand Lise recommended that the patient use the supplement Juven to support wound healing. For another patient, Lise recommended drinking orange juice with meals because the patient was complaining of sore gums and itchiness. Lise would also often make herself present at meal times, in the cafeteria, to watch what food choices patients make and to see how they are eating, more generally. 

The big project that I was tasked with during this week was creating a finger foods menu, or a safety tray menu, for the upcoming opening of AAMC’s new mental health hospital. All foods must be able to be eaten using no utensils, by hand. One page of this menu can be seen below. Lastly, at the end of this week, I helped Lise prepare for and present the weekly nutrition group lesson and activity. The lesson just happened to fall on Valentine’s Day, so we used the theme: how to fall back in love with your kitchen and with cooking. The patients love listening to music, so we prepared a Valentine’s Day playlist to get everyone excited. Lise bought lollipops and chocolate candies for everyone, and not only presented a fun nutrition lesson, but also made everyone feel welcomed and cared for on this special day. 

This is one page of the Finger Foods Menu that I created for the new mental health hospital.

The Stigma/Treatment Bias

When working with these patients and on a multidisciplinary care team, Lise emphasized that it is important to remember that there is incredible stigma and bias facing patients with SUD. She stressed that SUD, and addiction in general, should be thought of as a chronic disease, similar to diabetes or heart disease, rather than as a choice. I definitely agree, and hope to see more people in the medical field embrace this attitude.

Wrapping it All Up

I ended my four days feeling very excited and uplifted. This was because my preceptor was so kind, positive, and supportive. However, this was also due to the fact that BHN is a growing area of practice for dietitians. I am very excited by this fact and could definitely see this as a possible area of practice for myself in the future. My preceptor made sure that I left Pathways with not just a whole arsenal of BHN resources, but also with a sense of empowerment and excitement. 

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