Collaboration and
Communication:
Exploring the Roles of
Nutrition and Mental Health
Providers
Nutrition and Mental Health:
A front-line perspective
Kelly Matheson, Msc RD CDE
Inpatient Clinical Dietitian, Complex Mental Illness
Centre for Addiction and Mental Health, Toronto ON
Outline

The Dietitian’s role in mental health

Common nutrition-related concerns in mental
health

Special considerations when assessing clients

Challenges and research gaps

Brain-heart initiative, collaboration and advocacy
The Dietitian’s Role in Mental Health
“Registered dietitians help clients improve their
physical health, which is intertwined with mental
health. Improving physical health can improve
mental health and overall well-being”
The Dietitian’s Role in Mental Health

Clients with complex mental illness (or CMI) can be
very complex, with many layers

The role includes and expands beyond the following:

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Motivate and encourage healthier food and lifestyle
choices
Prescribing therapeutic diets
Early lifestyle interventions to delay or prevent long-term
complications (e.g. Diabetes)
Link to community programs and services
Therapeutic recreation (cooking groups, grocery shopping
tours)
Advocacy for better access to healthy food (e.g. boarding
homes)
Impaired
cognitive
function
No place to
call home
Comorbid
conditions
Addiction
Trauma history
Violence
towards self
and others
No insight
into illness
Lack of
employment
and skills
Voices and
hallucinations
Stigma
No family or
friends
Common Nutrition-Related
Concerns in Mental Health
 Medication
Side effects
 Concurrent medical diagnoses
 Delusions, hallucinations, food phobias
 Disordered eating/emotional eating
 Food insecurity
Medication Side-Effects
Some medications (called second generation
antipsychotics or SGA) taken by clients with CMI have
nutrition-related side effects
These side effects can include:
 Hyperphagia (increased appetite)
 Weight gain
 Fatigue
 Metabolic disturbances (insulin resistance, elevated
lipids)
 Constipation
 Tardive Dyskinesia (involuntary movements)
 Hyponatremia and/or polydipsia
Medication Side-Effects
Clozapine
Olanzapine
Metabolic risk
Risperidone
Quetiapine
Paliperidone
Aripiprazole
Lithium
Concurrent Medical Diagnoses

Individuals with chronic psychotic disorders die on
average 20 years before their peers and
predominantly (greater than 80%) of
cardiovascular diseases1

Chronic schizophrenia has been identified as an
independent risk factor for developing Type 2
Diabetes2

Obesity can be 2-3 times more prevalent in people
with CMI than in the general population3
1. Srihari et al. Cardiovascular mortality in schizophrenia: Defining a critical period for prevention. Schizophrenia Research. 2013; 146:64-68.
2. Canadian Diabetes Association, Clinic Practice Guidelines. 2013.
3. Aquila, R. Management of Weight Gain in People with Schizophrenia. Journal of Clinical Psychiatry. 2002; 63(4):33-36
Concurrent Medical Diagnoses

Chronic disease states such as metabolic syndrome,
dyslipidemia, hypertension, cancer, chronic kidney disease
and diabetes increase polypharmacy in clients with CMI,
who already take several medications for their mental illness
Delusions, Hallucinations, Food Phobias

Many clients with CMI experience food-related delusions,
hallucinations and phobias such as:
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Beliefs that their food is poisoned or “tampered” by others
Beliefs that they are a higher being (religious preoccupation) that does not
need food or water to sustain life
Beliefs that food is never “clean” (OCD behaviours)
Taste, smell and appearance changes of food
These symptoms may improve with the use of
antipsychotic medication, or remain chronically fixed
Delusions, Hallucinations, Food Phobias
Consequences:
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Significant unintentional weight loss
Macro/micronutrient deficiencies
Falls risk
Shows lack of insight and inability to care for self
(may require hospital admission)
Refeeding syndrome (rare but does occur)
Disordered Eating Behaviours and
Emotional Eating
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Chronic bingeing behaviours- increased appetite,
boredom, lack of routine
Heavy reliance on sugar and caffeine for energy “boosts”
Multiple life stressors leading to emotional/comfort eatingmental illness, medical diagnoses, trauma, lack of social
support, food insecurity, stigma
Smoking cessation, abstaining from substances can
increase reliance on food as a substitute
Food Insecurity

Many clients with CMI are on a limited income: ODSP, OW, CPP

Homelessness, unstable housing, boarding homes/group homes

Living in “food deserts”: low-income areas where healthy, lower cost
foods are not readily available
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Lack of knowledge of how to budget, shop, plan meals, use
appliances or prepare/cook food
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Heavy reliance on food banks, soup kitchens
Weight Gain
Special Considerations When
Assessing a Client in Mental Health
Some additional information that may help your assessment:
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Capacity (does client make their own treatment/financial
decisions?)
Weight history before/after starting SGA
Any other nutrition-related side effects of SGA
Appetite (changes, when it is high or low)
Supplement use/diet pills
Typical “routine”, including appointments, job, volunteering
(routine VERY important for CMI clients)
Special Considerations When
Assessing a Client in Mental Health
Continued…
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Daily/weekly budget for food, navigating the grocery store
Kitchen facilities- storage, shared space, cooking utensils etc.
“Safety plan” for times when client is unwell
Support system, access to community resources
Challenges and Research Gaps
ONION LAYERS!
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Medications cause increased appetite and also fatigue,
which both contribute to weight gain
Multiple co-morbidities: not just physical-clients may also be
dealing with mental health issues, addictions, emotional
regulation, and/or may be exploring work, school or
volunteer opportunities, and healthy eating and physical
activity may not be a priority
Fluctuating mental state
Negative symptoms of schizophrenia
Challenges and Research Gaps
ONION LAYERS!
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Food insecurity
Lack of options/choice secondary to housing
Cognitive challenges- some mental illness can cause
cognition problems
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Some people may process information as black or white
Cognitive problems may also be a result of years of substance abuse
Dual diagnosis (mental illness + retardation) – clients may have very limited
insight into their behaviours
Challenges and Research Gaps
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There is a lack of evidence-based guidelines on how
to adapt common techniques/counselling tools to a
client with mental illness:
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How do you apply motivational interviewing to
someone who is paranoid, or who has negative
symptoms?
Can the same harm-reduction approaches used in
addictions be applied to someone with schizophrenia
who can’t stop drinking pop?
Should a person on clozapine have the same
cholesterol targets as the general population?
Challenges and Research Gaps
As a Dietitian working in complex mental illness, it would be
great to see more research in:

Nutrition interventions as adjunctive treatment for
schizophrenia and schizoaffective disorder
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Nutrition monotherapies and the role of nutrient-based
supplements to address deficiencies in mental health
populations
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Guidelines and eating patterns for specific diagnoses
(e.g. the “Mood Diet” for mild to moderate depression
Gut-Brain-Microbiota Axis: Gut Psychology May Be
Considered the “Second Brain”
Grenham S, et al. Brain-gut-microbiota communication in health & disease. Front Physiol, 2011.
Dietitians in Mental Health Supporting the
Brain Heart Program
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Offering support/consultation in all stages of program
planning, implementation and evaluation
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Providing staff education (e.g. Wharton Clinic Dietitians) to
increase knowledge and confidence in working with clients
with Complex Mental Illness
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Monitor and encourage inpatient referral process (soft
launch, referral pathways, inpatient staff education)
Insights From My Placement
Experiences in the Mental
Health Field
Rachel Hicks, MPH, RD
Background
 Completed
combined dietetic
internship and MPH degree at U of T
2
out of 3 of my placements were in
mental health


CAMH (Spring 2015)
Waypoint (Winter 2016)
Nutrition Programming in Complex
Mental Illness
Capstone research paper: “Nutrition
Programming in Complex Mental Illness”
 Nutrition
programming & dietitians well
recognized in chronic disease
prevention/management.. Where are
they in mental illness populations?
 Where can nutrition programming and/or
dietitians fit in community setting?
Reflections
 Room
for mental health training for RDs
 Do RDs feel competent working with
mental illness populations?
 Where does advocacy fit?
 What can I do?
How can I share my thoughts?
What’s Next?
 Research
priorities/ identify gaps
 Advocacy
 Students, researchers willing to take on these
projects
 Learning modules for dietitians, other health
professionals working in mental health
Questions?
For More Information
Bridging the Divide
http://nutritionandmentalhealth.ca
Project Manager
Lisa Petermann
[email protected]