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

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

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

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

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

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

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

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.

THE EIGHT DIMENSIONS OF WELLNESS

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

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.”

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

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.

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

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

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

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.

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)

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

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.

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.

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.

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

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.

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?

• Essential nutrients profoundly
impact cells & brain chemistry
• Wernicke-Korsakoff Syndrome
(thiamine deficiency in AUD pts)
• Thiamine deficiency:
• Poor appetite, weakness,

irritability, depression

• 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

• Nutrient deficiencies: vitamin D
• Depression, mood disorders

• Will taking large amounts of
vitamin supplements fix this?
• Is severe malnourishment in
US likely?
• Possible?

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

• 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.

• 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

nutrition to mental health. Lincoln,
NE: iUniverse.

• 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

nutrition to mental health.
Lincoln, NE: iUniverse.

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.

• Two key neurotransmitters:
• Dopamine (DA)
• “Reward”

• Norepinephrine (made from DA)
• Mood, role in “fight or flight”
• Low levels associated with
depression and fatigue


• Tyrosine

• 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?

DOPAMINE (DA)
• Catecholamine neurotransmitter

• Dopamine is the major brain
chemical involved in addiction

• Important in
• Movement (muscle control)
• Motivation and attention

• Reward
• Well-being

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.

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

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.

FACTORS THAT REGULATE FOOD INTAKE
• Caloric requirements

• Reinforcing responses
• Palatability

• Conditioned responses
• Cues

• Cognitive control
• Inhibition/regulation

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

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.

• 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

• > 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

• 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

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

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

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

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

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

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

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.

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

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.

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

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.

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.

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.

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

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

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

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

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.

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

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

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?

COCA LEAF VS. CRACK COCAINE
Coca Leaf

Powder Cocaine

Crack Cocaine

• Not highly
addictive

• By-product
• Addictive

• Further processed
• Wreaks havoc on
human brain

POPPY PLANT VS. HEROIN
Poppy Plant

Raw opium

Heroin

• Not highly
addictive

• By-product
• Addictive

• Further processed
• Highly Addictive

WHEAT PLANT VS. WHITE FLOUR
Wheat Plant
• Not addictive

Whole Wheat
Flour

Refined White
Flour

• By-product

• Further
Processed
• “Offensive”

CORN VS. HIGH FRUCTOSE CORN SYRUP (HFCS)

Corn

Corn Syrup

HFCS

• Not addictive

• By-product

• Further Processed
• “Offensive”

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”

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.”

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”?

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


What is the
difference between
a baked potato and
French fries with
ketchup?

Fat…Salt…Sugar


Refined grains…

w/ sugar/salt/fat

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

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.

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

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?

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.

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

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.

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

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

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.

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”

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”

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

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.

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

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.”

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

“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.

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

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.
Toronto, CAN: Centre for Addiction and Mental
Health.

“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

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.

“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

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

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!

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

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

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

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

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.

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.

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.

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

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

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

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

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

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

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

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.

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

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

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

RECS – OPIATES
• Liquid MVI (low metal)
• Additional vit. B6
• Additional calcium and vit. D
• Digestive enzymes, probiotics
• Fiber supp if constipated

• Higher caloric needs?

RECS – COCAINE
• MVI (low metal)

• Omega-3 supp DHA rich
• Protein-rich diet
• 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

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

SOURCES OF VITAMIN A

• Carrots
• Pumpkin
• Sweet Potato
• Kale

SOURCES OF VITAMIN C
• Bell Peppers
• Kiwi
• Broccoli
• Strawberries

SOURCES OF VITAMIN E

• Almonds
• Sunflower Seeds
• Turnip Greens
• Peanut Butter

SOURCES OF SELENIUM
• Brazil Nuts
• Yellowfin Tuna
• Turkey
• Halibut

SOURCES OF IRON
• Red meat

• Lentils
• Pumpkin seeds
• Kidney beans

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

Goal:
To introduce nutrition as
an important
component of recovery
and to encourage
behavior change with
respect to food

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

• 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

• 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

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

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)

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

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?

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”

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”

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”

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

WHAT CAN THE RDN DO AS A MEMBER OF THE
TREATMENT TEAM?

WHAT CAN THE
TREATMENT
CENTER DO?

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

“Food for thought
is no substitute for
the real thing.”
~ Walt Kelly

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!

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 

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?

It Is Not Enough To Stare
Up The Steps; We Must
Step Up The Stairs

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

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

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

Similar to Nutrition Interventions in Addiction Recovery: The Role of the Dietitian in Substance Abuse Treatment 2013 (20)

More from Nutrition in Recovery

More from Nutrition in Recovery (6)

Recently uploaded

Recently uploaded (20)

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

Editor's Notes