Nutrition and Psychiatric Patients
Today’s Dietitian
By Mary Anne Clairmont, RD
Vol. 6, No. 8, p. 40

Psychiatric symptoms can lead to nutritional neglect. But treatment often means weight gain. What can dietitians do about this catch-22 of psychiatric care?

What relationships exist between nutrition and psychiatric conditions? Most of these relationships occur incidentally rather than deliberately. If not addressed properly, they can have a negative impact on nutritional status. But they can be successfully manipulated to achieve positive benefits for patients.

Dietitians treating psychiatric patients should review several factors in patients’ lives, including the following:
• Medications used for psychiatric patients can contribute to weight gain.
• Psychiatric patients may gain weight because they make poor food choices for a number of reasons.
• Patients may gain weight because they overeat to feel better and/or they are bored yet unmotivated or not directed to engage themselves in other activities.
• Many therapy programs use food as a reward for good behavior in patients.
• Therapists and nutritionists use exercise as an integral part of therapy to raise endorphins and promote the concept of self-care.
• Patients with cognitive deficits due to psychosis and those suffering from addictions usually neglect their nutritional needs. These patients are likely to have the greatest physical problems due to homelessness, exposure to hepatitis, HIV infection, tuberculosis, and severe strain on their liver.

Dietitians must take a multidisciplinary approach to best identify and treat psychiatric patients. The treatment team must recognize which factors are contributing to weight gain before a successful treatment plan can be developed.

Gaining Weight
Weight gain is the major reason patients stop taking antipsychotic medications. Weight gain was documented and studied more than a century ago, before modern psychotropic medications were discovered. Therefore, we can assume that some causes of weight gain are not drug-related.

Helpful questions to explore when looking for non–drug-related causes for weight gain in psychiatric patients are:
• Do the medications used for this patient contribute to weight gain? Do they increase the patient’s appetite? Are they known to alter glucose or insulin levels?
• Are there other reasons the psychiatric patient is gaining or has gained weight?
• Did the patient gain weight because he or she made poor food choices?
• Did the patient gain weight because he or she overeats to feel better?
• Does the patient eat to soothe or console himself or herself?
• Does the patient function at a limited cognitive level with few recreational activities to look forward to? Does this lead to frequent boredom?

The entire treatment team should be involved in gathering this information. It depends on the status of your patient. If the patient is able to communicate effectively and tell you the answers to these questions, that is ideal. Sometimes the answers do not appear straightforward until you, the professional, are acclimated to the question-and-answer process of psychiatric patients. The team members’ assistance is indispensable, as is the information you can gather from the patient’s medical record.

The Case of Bob
Let’s consider Bob*, a psychiatric patient whose cognitive abilities are limited as a result of his illness. Reading a best-selling novel is beyond this patient’s capabilities, as is following most television sitcoms, crossword puzzles, and solitaire. Meals and snack time are the most rewarding activities Bob has to look forward to each day. While each day is well-structured with therapy sessions, group therapy, and therapeutic recreation, he does have some free time. Bob will spend a great deal of his free time at the nurse’s station asking if there are any extra or leftover snacks. He will answer “yes” if you ask him if he is hungry, even if you ask him while he is walking back to his unit from the cafeteria immediately after a meal. Bob is preoccupied with food.

When patients become fixated on food, the real problem is not the food but the lack of appropriate recreational activities accessible to the patient.

A creative team approach with all disciplines contributing to a solution is the best method for treating psychiatric patients. The dietitian assesses the patient’s food intake; effects of medication on appetite; clinical factors that may affect appetite, such as fluctuations in glucose levels; and factors such as behavioral, emotional, and cognitive status.

In Bob’s case, the dietitian recognized that he was overly focused on food because he didn’t have enough activities to look forward to. She addressed this problem at a team meeting and the other team members concurred. The allied therapist had some wooden puzzles with bright, attractive pieces of circus items. She believed Bob would be interested in these because he always enjoyed circus stories and went to the circus every year with his father as a child. A nurse on the team had several lively videos and CDs about the circus at home that her children no longer watched. The videos appealed to levels ranging from prekindergarten to grade four.

The dietitian told the team that Bob frequently talked about working with his mother in the garden at home. Occupational therapy was able to set Bob up with an indoor window box garden where he grew vegetables he enjoys, such as radishes and leaf lettuce. Bob harvested the vegetables under supervision and ate them as frequent snacks.

The dietitian talked about nutrition and healthful eating with Bob. She provided simple and effective education and counseling for him, and he changed many eating behaviors. Bob was quite proud of his homegrown snacks and grasped the importance of eating properly.

Even patients with cognitive impairment are capable of understanding the relationship between eating well and good health. They need specific directions on how to accomplish this and a reason to want good health. Bob loved his homegrown foods and they were more appropriate to reducing his weight than the snacks and extra portions he had been eating in the cafeteria. The day he invited the dietitian to join him in a snack of fresh vegetables he prepared, it was clear Bob had internalized changes in his nutritional behavior.

Mastering Motivation
Patients need reasons to want good health to continue so they can be motivated to progress with their positive behaviors.
Many therapy programs use food as a reward for good behavior in patients. Is this a reason patients become overweight? Meet with the therapists using food in behavior programs. Find out how the food is being used and the status of the patients receiving the food.

In many groups, it may be appropriate to have food to promote a sense of community since food has a social aspect. In these cases, use the opportunity to integrate foods consistent with your “good nutrition, healthy eating for all” policy into the group. In some cases, the dietitian will give short nutrition information sessions or run regular group therapy sessions depending on his or her expertise.

Psychotic patients are in dire need of medication. It may take weeks or months before medications can be balanced properly. These patients can be hyperactive, violent, and unable to communicate with staff. However, food may be a powerful motivator for these patients, even though using food as a reward can be considered a bribe. (Therapists are sometimes criticized for using food as a reward—this is a unique situation.)

Consider that psychiatric patients are functioning poorly and responding to few motivators. Many times the food can be nutrient-dense. The dietitian, along with the therapist, must determine the most acceptable foods to use and include the patient in this decision if he or she is able to participate.

Medication Minefield
Medications used to treat psychiatric disorders have numerous side effects. Undesired weight gain and changes in blood sugar are two disturbing effects of medications used to treat psychiatric disorders. There is a growing body of evidence documenting a relationship between psychotropic medications and weight gain, although an undisputable cause and effect can’t always be proven. Individual differences of each patient and their reactions to a pharmaceutical agent will vary.

Currently, several different theories are accepted as possible explanations for various psychotropic drugs that contribute to weight gain in susceptible patients. Medications that antagonize 5-HT2c and H1 receptors and those that block D2 or dopamine receptors are associated with weight gain.

Medications block serotonin transmission by interfering with 5-HT2c receptors. Medications that interfere with histamine or H1 receptors are also associated with weight gain. The tricyclic antidepressants block H1 receptors. Some of the newer generation of antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), cause an initial weight loss but then contribute to weight gain.

Genetic predisposition may protect certain individuals from the negative effects of SSRIs. People with a genetic polymorphism of the 5-HT2c receptor are not susceptible to the weight gain that affects others taking SSRIs.

Macronutrient partitioning shift is a metabolic phenomenon dietitians working with psychiatric patients have recognized for many years. Only recently did it receive an official name.

Olanzapine, risperidone, and haloperidol were compared in one study that showed an increase in hunger and use of carbohydrates for fuel and decreased use of fat as fuel. These metabolic changes are believed to be responsible for carbohydrate craving, increased appetite, and weight gain in some individuals.

Clozapine is associated with lipid abnormalities, weight gain, and increased risk for diabetes in some individuals. Olanzapine and quetiapine appear to affect blood sugar levels, causing elevated glucose levels in many individuals. These drugs are also linked to weight gain.

The side effects of several psychotropic medications significantly affect blood sugar levels and diabetes. Identification and treatment of patients with psychiatric disorders susceptible to the glucose-elevating effects of certain medications is a topic of major concern among RDs and healthcare providers who treat this population.

Solutions To Drug-Induced Weight Gain
A simple answer is to switch the medication. However, psychiatric patients may respond well only to specific medications at meticulously calculated doses. Also, switching to a medication in the same class may be the only option for certain disorders and the new medication might produce the same side effects.

Activity and dietary changes can be successful in counteracting the weight gain associated with psychotropic medications. Even patients with cognitive impairments and limited insight to their problems will benefit when approaches are tailored to their specific needs.

RDs should concentrate on strategies that get patients to act rather than extensive education, which does not motivate or model appropriate behaviors.

A direct approach telling patients exactly what they must do on a regular schedule is effective for some patients who willingly accept directions from their care providers.
Having patients walk for 45 minutes on Monday, Wednesday, Friday, and Saturday—unless they are ill or it is raining—is a plan that will work to increase activity levels. Individual and group programs can complement each other to achieve patient success.

Diminished general nutrition status is a risk factor in patients with a history of psychotic disorders, addictions, anxiety disorders, depression, and panic disorders. These disorders can prevent people from performing the most basic activities of daily living effectively, including eating well.

The cognitive impairments and other effects of living with these disorders take a heavy toll on health and nutritional well-being. Psychotic individuals who need medication and therapy may suffer from nutritional depletion due to their inability to secure food and prepare it for themselves. They may also feel too manic, depressed, anxious, or confused to eat. These patients may be unable to realize they are not eating well because their psychiatric illness impairs their judgment.

Even patients who exceed acceptable body weights are at risk for nutrient deficiencies. They may eat high-calorie and high-fat processed snack and convenience foods that are low in a variety of nutrients necessary for good health. Foods low in the diet are frequently fresh fruits and vegetables, milk, and whole grains.

Patients need to be assessed for deficiencies through food histories if they are lucid and can communicate this information. If they are unable to communicate this information, the dietitian can use information from the former living arrangements of the patient, family input if available, anthropometric measurements, laboratory values, and background from the patient’s social worker to put together a picture of the patient’s nutritional status.

Substance Abuse
Substance abusers may lose all appetite and have limited access to food depending on their financial circumstances.

In addition to a multivitamin, alcohol and substance abuse patients will usually need thiamine, pyridoxine, and vitamin C supplementation on a routine basis. Specific drugs tend to cause depletion of certain nutrients. Drugs in the opiate family tend to cause decreased calcium absorption, increased cholesterol levels, and increased body potassium.

Pyridoxine, thiamine, and vitamin C are depleted in alcoholics because of the toxic effect alcohol abuse has on the liver and pancreas. Iron levels are often abnormal, as well as liver function tests in patients with liver disease. Vitamin K will be low in patients with liver damage. Calcium absorption is disturbed in addicts, and women are especially at risk for osteoporosis. They need calcium supplementation and improved calcium food intake.

Substance abusers are at risk for hepatitis B and C as well as HIV and sexually transmitted diseases. These all have a critical nutrition component in their treatment plan.

Creativity and Teamwork
Some dietitians may believe working with psychiatric patients is not going to utilize their clinical skills. This is not true. Not only are good clinical skills vital to the RD, but a measure of creativity in implementing them is indispensable in the psychiatric setting.

Working with an interdisciplinary team is both a joy and challenge for the dietitian. It provides unlimited opportunities to the RD to expand his or her skills beyond nutrition. Just as the dietitian asks team members for input on nutrition issues, the dietitian will be asked to participate in problem solving by the other team members with issues outside of nutrition. These opportunities enrich the dietitian’s knowledge base by learning other disciplines. Teamwork enables the dietitian to see the patient’s nutrition status as one of many issues that intersect. It also provides the dietitian opportunities to see how other disciplines approach and solve problems that may not be typically used in nutrition care. Dietitians can help develop creative solutions to problems of psychiatric patients. Psychiatric health is a rewarding and exciting field with unique opportunities for dietitians in patient care and staff education.

* Name is fictitious

— Mary Anne Clairmont, RD, is the nutritionist at Fairmount Behavioral Health System and of Take Two Nutrition, a nutrition consulting company in Plymouth Meeting, Pa.

Subscribe to Today's Dietitian Magazine!