In a Children’s Psychiatric Hospital

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The number of children’s psychiatric hospitals in the U.S. is growing (www.ushosptial.info). I am the clinical dietitian of a children’s psychiatric hospital in Georgia. This hospital treats eighty children and is always full with a waiting list for admission. Approximately 86 percent of admissions are boys; 92 percent are African-American, and 65 percent are readmissions. Medicare and Medicaid pay for all admissions.

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DIAGNOSIS AND TREATMENT

The hospital provides psychiatric and mental health treatment for mood, behavior and anxiety disorders for children and adolescents between the ages of nine and seventeen. Some of the children have committed crimes and are too young to be imprisoned. Most are diagnosed with “conduct disorder,” which means that their parents are unable to manage them. Other children have disorders manifested from family neglect and abuse. At times the hospital seeks to place children in a group or foster home following therapy.

Other psychiatric diagnoses might include anxiety, ADHD, mental retardation, chronic fatigue, substance abuse and self-mutilation. Medical diagnoses include diabetes, hypertension, and hyperlipidemia (high cholesterol and/ or triglycerides). Most children present with multiple diagnoses.

My job responsibility at this facility is to complete an initial assessment of each patient, addressing special diet orders written by the physician. I evaluate blood levels, if test reports are available, for vitamin deficiency. I am expected to recommend lowfat diet protocols for hyperlipidemia and monitor weight trend during the hospitalization. I feel that the true reason a dietitian is employed at most facilities is to meet state guidelines for reimbursement rather than to implement genuine nutritional therapy for these children.

If a diet instruction is performed, it must be ordered by the physician. Only one diet instruction has been requested in my three years of working at this facility, despite the fact that most of the children eat horribly and many are morbidly obese. That single diet instruction had been ordered for a lowfat, low-cholesterol diet to “lower cholesterol” in a thirteen-year-old patient taking a statin drug.

Most physicians believe that diet changes are not important, especially if the patient returns to a home environment where the family cannot provide proper foods because of financial strictures or other reasons. The hospital’s treatment plan is wholly based upon, and reliant upon, pharmaceutical intervention. Changing dietary habits is not, and never was, a part of the treatment plan.

Based on an actual patient, a typical diagnosis and treatment plan for a sixteen-year-old African-American male might look like this:

DIAGNOSIS:

Bipolar
ADHD
Mild mental retardation (low IQ)
Oppositional/defiant behavior
Depression: two past suicide attempts
Hypertension
Hyperlipidemia
Morbid obesity:
Height: 64 inches,
Weight: 242 pounds
Body mass index: 41

TREATMENT:

Lipitor – high cholesterol
Clonidine – blood pressure,
ADHD Lithium – bipolar, depression
Seroquel – bipolar
Metformin – to control the increased appetite caused by Seroquel
Social Services – (social worker)

A diet instruction for this patient was not requested. The patient’s diet history is poor, consisting mostly of refined foods and sugars. The patient does not drink milk and receives little sunshine. No blood nutritional levels were drawn. No vitamin or mineral therapy is in place.

A HOLISTIC APPROACH

The patient discussed above is taking Seroquel, a frequently prescribed psychotropic medication. A side effect of this medication is increased appetite and weight gain. The patient was later prescribed Metformin to suppress the increased appetite caused by the Seroquel. This medication, usually used to control blood glucose in diabetics, is often prescribed to control appetite in adolescents.^1,2

Metformin is the diabetes drug I often think of when I think of nutrient depletion. Metformin is thought to decrease the absorption of vitamin B₁₂ by lowering intrinsic factor in the gut—which is necessary for the absorption of this vitamin—or possibly through other mechanisms.^3,4 Reduced B₁₂ serum levels occur in up to 30 percent of those individuals who take Metformin chronically. Those with a higher risk of developing the deficiency include this group of adolescent patients, whose diet is poor and whose vitamin B₁₂ intake is most likely inadequate.² At B₁₂ levels only slightly lower than normal for a very short period of time, a range of symptoms such as poor memory, fatigue, and depression may be experienced.⁵

A holistic medical approach would treat the “source” of this patient’s disorders, which might include nutritional deficiency. It would be appropriate in this case to evaluate B₁₂ blood levels, especially since the child presents with two of the symptoms typically caused by B₁₂ deficiency. If B₁₂ was found to be low, analyze B₁₂ intake as well as the patient’s ability to absorb B₁₂ and then suggest vitamin supplementation if he was unable to meet his increased B₁₂ requirements through diet alone.

Vitamin D levels should also be evaluated, given the fact that this patient does not drink milk and spends most of his days indoors, along with a diagnosis which many studies link to low vitamin D levels.^6,7 In my three years of working at this hospital I have never seen a pateint’s vitamin D or B₁₂ levels tested or nutritional supplementation initiated.

A healthy diet program of whole, unrefined foods that work within the family budget should be initiated. The entire family should be involved in this new nutritional plan.

This approach should not devalue the benefit accomplished by pharmaceutical intervention, which is often necessary. Pharmaceutical therapy to suppress symptoms in combination with healing modalities such as nutritional therapy would be the ideal approach.

THE REALITY

The prospect of treating psychiatric conditions nutritionally with or without pharmaceutical intervention is promising and researched, but rarely implemented in practice. I think nutritional therapy is not part of the treatment plan nor is it sought because the physician conducts the treatment plan and is not aware of or does not understand a nutrition-based therapy approach.

Unless physicians have studied outside the parameters of the pharmaceutical industry presentation, they only understand how to treat a disease process pharmaceutically. A physician’s education and continuing education (classes, seminars, workshops, books, articles, studies) are all conducted and presented via a pharmaceutical partner or investment partner who is financially involved and motivated within the industry.

Other physicians believe that a therapy must be firmly grounded in “proven” fact before utilized; an assurance only afforded by the pharmaceutical industry since research studies are expensive to conduct.

My greatest frustration is in observing how reluctant physicians are to give up “control” of the patient, never asking another practitioner’s advice about a treatment they do not understand, even if the treatment is safe and has no ill side effects.

GOOD NEWS

These days I observe more pharmacists, nutritionists, and researchers conducting evidence-based studies on the dangers and side effects of pharmaceutical therapy. “Natural Medicines Database” (http://naturaldatabase.therapeuticresearch.com) is a good reference, providing a list of medications that cause nutritional depletion, with corresponding backup studies. The site provides information on the medications’ side effects as well as other herbal or homeopathic remedies that may be used alternatively. It lists evidence-based studies linked to the use of herbal and homeopathic remedies and encourages researchers to study and submit material.

I find it encouraging that this is a reference suggested by the Academy of Nutrition and Dietetics (American Dietetic Association)–Dietitians in Functional and Integrative Medicine practice group.

FOOD

On my first day of work at this hospital three years ago the administrator requested that I change the menu plan. After seeing the menu, I assumed he’d made the request because the menu contained so many refined foods and sugars. I later found it was because the patients were complaining about the food.

Here is what the menu plan looks like. It faithfully follows the guidelines of the Academy of Nutrition and Dietetics (American Dietetic Association):

Breakfast:

Eggs
Sausage/Bacon
Toast/Biscuit/Muffin/Sweet Roll/
Pop Tart/Pancakes
Cold Cereal /Oatmeal
Lowfat or Skim Milk
Fruit Juice

Lunch/Dinner:

Chicken Nuggets
Pizza
Hot Dogs/Hamburger
Fried/ Baked Chicken
Tacos
Salad or Vegetable
French Fries/Potatoes
Roll/Bread
Cake/Cookies
Lowfat Ice Cream/Sherbert
Canned/Fresh Fruit
Lowfat or Skim Milk
Fruit Punch/Lemon Lime Soda

Snacks:

Pre-packaged crackers, cookies or chips
Fruit juice/Fruit Punch/Lemon Lime Soda
Lowfat or Skim milk

All menu items are frozen, pre-packaged or canned, with the exception of salads or some fruit which may be fresh. I had big plans for changing this menu, hoping to meld WAPF principles into the guidelines of the Academy of Nutrition and Dietetics and teach the patients about dietary changes with classes.

The administrator asked me to first interview the patients to find out what they did not like about the food (the real reason he had consulted me) and what they would prefer instead. These are some of the patients’ requests:

Ranch dressing with everything—the lowfat type because it is sweeter
Froot Loops and Cocoa Puffs cereals
Chocolate milk
Chicken wings with BBQ sauce dip
Ketchup at every meal
Coke or Pepsi
Sugar substitute in the pink package
Icing on cakes
Coffee
Red Bull energy drink

When these same patients were asked what they thought they should eat in order to be healthier their answers included:

Cereal
Oatmeal
Ensure
Energy bars
Gatorade/Sports drinks
Lowfat and nonfat foods

Virtually all of the children obtained their nutrition education from television commercials.

I approached the administrator with a proposal to provide healthier meals and snacks, consisting of less sugar and refined foods, and to start weekly nutrition classes for the patients. I let him know the cost of the meals would increase, as well as the cost for me to conduct the classes. I also informed him that this was not what the patients themselves had requested. My proposal was immediately vetoed, followed by an explanation that the hospital must contain costs.

A few months later I was asked to conduct nutrition classes for patients in order to meet state funding requirements. I found the instruction difficult, as I ended up directing the patients to avoid the very foods that were served.

CONCLUSION

Treatment success in the hospital setting looks only at superficial results. Outward appearance is not the inward reality. These children are not healing from disease at this hospital. The treatment is merely combating or masking symptoms via pharmaceutical intervention. To truly heal these children, physicians must willingly turn to practitioners with training outside of the pharmaceutical model in the treatment plan.

We must end the monopoly that the pharmaceutical and refined food industries hold on nutrition and health care. Until we do, we as a nation will only become sicker—at ever younger ages—while the current medical model of invasive and pharmaceutical interventions burgeons entirely out of control.

REFERENCES

1. G Paoliso, Effect of metformin on food intake in obese subjects. European Journal of Clinical Investigation 28: 6 (June 1998):441-446.

2. MB Davidson. An overview of metformin in the treatment of type II diabetes mellitus. American Journal of Medicine 102: 1 (Jan 1997) 101-110.

3. Callagan TS, Megaloblastic anemia due to Vitamin B₁₂ malabsorption associated with long term metformin treatment. Br Med J 1980;280 1214-16.

4. Gilligan MA, Metformin and B₁₂ deficiency. Arch Internal Medicine 2002.162:484-5.

5. Dietary Supplement Fact Sheet – B₁₂. Office of Dietary Supplements, National Institute of Health. 28 September 2011.

6. http://www.naturalnews.com/031273_vitamin D_depression. html

7. http://vitamindcouncil.org/health-conditions/mentalhealth-and-learning-disorders/depression.html

 

This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Spring 2012.

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