Diets

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Diets

Definition

Purpose

Special diets for specific disorders

Dietary considerations and medications

Caffeine-restricted diet

Alcohol-restricted diet

Resources

Definition

Special diets are designed to help individuals make changes in their usual eating habits or food selection. Some special diets involve changes in the overall diet, such as diets for people needing to gain or lose weight or eat more healthfully. Other special diets are designed to help a person limit or avoid certain foods or dietary components that could interfere with the activity of a medication. Still other special diets are designed to counter nutritional effects of certain medications.

Purpose

Special diets are used in the treatment of people with certain mental disorders to:

identify and correct disordered eating patterns.
prevent or correct nutritional deficiencies or excesses.
prevent interactions between foods or nutrients and medications.

Special types of diets or changes in eating habits have been suggested for people with certain mental disorders. In some disorders, such as eating disorders or substance abuse , dietary changes are an integral part of therapy. In other disorders, such as attention deficit/hyperactivity disorder , various proposed diets have questionable therapeutic value.

Many medications for mental disorders can affect a person’s appetite or nutrition-related functions such as saliva production, ability to swallow, bowel function, and activity level. Changes in diet or food choices may be required to help prevent negative effects of medications.

Finally, interactions can occur between some medications used to treat people with mental disorders and certain foods or nutritional components of the diet. For example, grapefruit and apple juice can interact with some specific psychotropic drugs (medications taken for psychiatric conditions) and should be avoided by individuals taking those medicines.

Tyramine, a natural substance found in aged or fermented foods, can interfere with the functioning of monoamine oxidase inhibitors (MAOIs) and must be restricted in individuals using these types of medications. A person’s preexisting medical condition and nutritional needs should be taken into account when designing any special diet.

Special diets for specific disorders

Eating disorders

The two main types of eating disorders are anorexia nervosa and bulimia nervosa. Individuals with anorexia nervosa starve themselves, whereas individuals with bulimia nervosa usually have normal or slightly above normal body weight but engage in binge eating followed by purging with laxatives, vomiting, or exercise.

Special diets for individuals with eating disorders focus on restoration of normal body weight and control of bingeing and purging. These diets are usually carried out under the supervision of a multidiscipli-nary team, including a physician, psychologist , and dietitian.

The overall dietary goal for individuals with anorexia nervosa is to restore a healthy body weight. An initial goal might be to stop weight loss and improve food choices. Energy intake is then increased gradually until normal weight is restored. Because individuals with anorexia nervosa have an intense fear of gaining weight and becoming fat, quantities of foods eaten are increased very slowly so that the patient will continue treatments and therapy.

The overall dietary goal for individuals with bulimia nervosa is to gain control over eating behavior and to achieve a healthy body weight. An initial goal is to stabilize weight and eating patterns to help individuals gain control over the binge-purge cycle. Meals and snacks are eaten at regular intervals to lessen the possibility that hunger and fasting will trigger a binge. Once eating behaviors have been stabilized, energy intake can be gradually adjusted to allow individuals to reach normal body weights healthfully.

For individuals with either anorexia nervosa or bulimia, continued follow-up and support are required even after normal weight and eating behaviors are restored, particularly since the rate of relapse is quite high. In addition to dietary changes, psychotherapy is an essential part of the treatment of eating disorders and helps individuals deal with fears and misconceptions about body weight and eating behavior.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) accounts for a substantial portion of referrals to child mental health services. Children with ADHD are inappropriately active, easily frustrated or distracted, impulsive, and have difficulty sustaining concentration. Usual treatment of ADHD involves medication, behavioral management, and education.

Many dietary factors have been proposed as causes of ADHD, including sugar, food additives, and food allergies. In the 1970s the Feingold diet became popular for treatment of ADHD. The Fein-gold diet excludes artificial colorings and flavorings, natural sources of chemicals called salicylates (found in fruits), and preservatives called BHT and BHA. Although scientific evidence does not support the effectiveness of the Feingold diet, a modified Feingold diet including fruits has been shown to be nutritionally balanced and should not be harmful as long as the child continues to receive conventional ADHD treatment also.

A high intake of sugar and sugary foods has also been implicated as a cause of ADHD. Although carefully controlled studies have shown no association between sugar and ADHD, diets high in sugar should be discouraged because they are often low in other nutrients and can contribute to dental problems.

Food allergies have also been implicated as a cause of ADHD, and some groups have suggested using elimination diets to treat ADHD. Elimination diets omit foods that most commonly cause allergies in children, such as eggs, milk, peanuts, or shellfish. Although research does not support the value of elimination diets for all children with ADHD, children with specific food allergies can become irritable and restless. Children with a suspected food allergy should be evaluated by an allergist.

Stimulant medications used to treat ADHD, such as methylphenidate (Ritalin), can cause appetite loss (anorexia) and retard growth, although recent research suggests that a child’s ultimate height appears not to be affected by stimulant medications. As a precaution, children on such medicines should receive close monitoring of growth patterns, and parents should carefully observe their child’s appetite and interest in meals and snacks. Providing regular meals and snacks, even when the child is not hungry, can help to assure adequate growth.

Mood disorders

Mood disorders include both depression (unipolar disorder) and episodes of mania followed by depression (bipolar disorder ). Both types of disorders can affect appetite and eating behavior.

Although some individuals with depression eat more than usual and gain weight, depression more often causes loss of appetite and weight loss. As individuals with depression lose interest in eating and social relationships, they often skip meals and ignore feelings of hunger. Unintentional weight losses of up to 15% of body mass can occur.

Treatment with antidepressant medications often reverses weight loss and restores appetite and interest in eating. If individuals have lost a significant amount of weight, they may need to follow a high-calorie diet to restore weight to normal levels and replaced nutritional deficiencies. High-calorie diets usually include three balanced meals from all the food groups and several smaller snacks throughout the day. A protein/calorie supplement may also be necessary for some individuals.

Depression is sometimes treated with (MAOIs). Individuals on these medications will need to follow a tyramine-restricted diet.

Individuals with mania are often treated with lithium. Sodium and caffeine intake can affect lithium levels in the blood, and intake of these should not suddenly be increased or decreased. Weight gain can occur in response to some antidepressant medications and lithium.

Schizophrenia

Individuals with schizophrenia can have hallucinations , delusional thinking, and bizarre behavior. These distorted behaviors and thought processes can also be extended to delusions and hallucinations about food and diet, making people with schizophrenia at risk for poor nutrition.

Individuals with schizophrenia may believe that certain foods are poisonous or have special properties. They may think they hear voices telling them not to eat. Some may eat huge quantities of food thinking that it gives them special powers. Individuals with untreated schizophrenia may lose a significant amount of weight. Delusional beliefs and thinking about food and eating usually improve once individuals are started on medication to treat schizophrenia.

Substance abuse

Substance abuse can include abuse of alcohol, cigarettes, marijuana, cocaine , or other drugs. Individuals abusing any of these substances are at risk for nutritional problems. Many of these substances can reduce appetite, decrease absorption of nutrients into the body, and cause individuals to make poor food choices.

Special diets used for withdrawal from substance abuse are designed to correct any nutritional deficiencies that have developed, aid in the withdrawal of the substance, and prevent the individual from making unhealthful food substitutions as the addictive substance is withdrawn. For example, some individuals may compulsively overeat when they stop smoking, leading to weight gain. Others may substitute caffeine-containing beverages such as soda or coffee for an addictive drug. Such harmful substitutions should be discouraged, emphasizing well-balanced eating combined with adequate rest, stress management, and regular exercise. Small, frequent meals and snacks that are rich in vitamins and minerals from healthful foods should be provided. Fluid intake should be generous, but caffeine-containing beverages should be limited.

Individuals withdrawing from alcohol may need extra thiamin supplementation, either intravenously or through a multivitamin supplement because alcohol metabolism in the body requires extra thiamin. Individuals taking drugs to help them avoid alcohol will need to avoid foods with even small amounts of alcohol.

Common withdrawal symptoms and dietary suggestions for coping with these symptoms include:

appetite loss: Eat small, frequent meals and snacks; limit caffeine; and use nutritional supplements if necessary.
appetite increase: Eat regular meals; eat a variety of foods; and limit sweets and caffeine.
diarrhea: Eat moderate amounts of fresh fruits, vegetables, concentrated sugars, juices, and milk; and increase intake of cereal fiber.
constipation: Drink plenty of fluids; increase fiber in the diet; and increase physical activity.
fatigue: Eat regular meals; limit sweets and caffeine; and drink plenty of fluid.

Dietary considerations and medications

Medications that affect body weight

Many medications used to treat mental disorders promote weight gain, including:

anticonvulsants (divalproex)
certain types of antidepressants (amitriptyline)
antipsychotic medications (clozapine, olanzapine, quetiapine, and risperidone)

Dietary treatments for individuals taking these medications should focus on a balanced, low-fat diet coupled with an increase in physical activity to counter the side effects of these medications. Nutrient-rich foods such as fruits, vegetables, and whole grain products should be emphasized in the diet, whereas sweets, fats, and other foods high in energy but low in nutrients should be limited. Regular physical activity can help limit weight gain caused by these medications.

Some medications can cause loss of appetite, restlessness, and weight loss. Individuals on such medications should eat three balanced meals and several smaller snacks of protein and calorie-rich foods throughout the day. Eating on a regular schedule rather than depending on appetite can help prevent weight loss associated with loss of appetite.

Medications that affect gastrointestinal function

Many psychiatric medications can affect gastrointestinal functioning. Some drugs can cause dry mouth, difficulty swallowing, constipation, altered taste, heartburn, diarrhea, or nausea. Consuming frequent smaller meals, drinking adequate fluids, modifying texture of foods if necessary, and increasing fiber content of foods can help counter gastrointestinal effects of medications.

Monoamine oxidase inhibitors

Individuals being treated with MAOIs such as tranylcypromine, phenelzine , and isocarboxazid, must carefully follow a tyramine-restricted diet. Tyramine, a nitrogen-containing substance normally present in certain foods, is usually broken down in the body by oxidase. However, in individuals taking MAOIs, tyramine is not adequately broken down and builds up in the blood, causing the blood vessels to constrict and increasing blood pressure.

Tyramine is normally found in many foods, especially protein-rich foods that have been aged or fermented, pickled, or bacterially contaminated. Cheese is especially high in tyramine. A tyramine intake of less than 5 mg daily is recommended. A diet that includes even just 6 mg of tyramine can increase blood pressure; a diet that provides 25 mg of tyramine can cause life-threatening increases in blood pressure.

TYRAMINE-RESTRICTED DIET

Tyramine is found in aged, fermented, and spoiled food products. The tyramine content of a specific food can vary greatly depending on storage conditions, ripeness, or contamination. Reaction to tyramine-containing foods in individuals taking MAOIs can also vary greatly depending on what other foods are eaten with the tyramine-containing food, the length of time between MAOI dose and eating the food, and individual characteristics such as weight, age, etc.

Foods to avoid on a tyramine-controlled diet include:

all aged and mature cheeses or cheese spreads, including foods made with these cheeses, such as salad dressings, casseroles, or certain breads
any outdated or nonpasteurized dairy products
dry fermented sausages such as summer sausage, pepperoni, salami, or pastrami
smoked or pickled fish
nonfresh meat or poultry
leftover foods containing meat or poultry
tofu and soy products
overripe, spoiled, or fermented fruits or vegetables
sauerkraut
fava or broad beans
soups containing meat extracts or cheese
gravies containing meat extracts or nonfresh meats
tap beer
nonalcoholic beer
yeast extracts
soy sauce
liquid powdered protein supplements

Perishable refrigerated items such as milk, meat, or fruit should be eaten within 48 hours of purchase. Any spoiled food and food stored in questionable conditions should not be eaten.

Lithium

Lithium is often used to treat individuals with mania. Lithium can cause nausea, vomiting, anorexia, diarrhea, and weight gain. Almost one-half of individuals taking lithium gain weight.

Individuals taking lithium should maintain a fairly constant intake of sodium (found in table salt and other food additives) and caffeine in their diet. If an individual restricts sodium intake, less lithium is excreted in the urine and blood lithium levels rise. If an individual increases caffeine intake, more lithium is excreted in the urine and blood levels of lithium fall.

Anticonvulsant medications

Sodium caseinate and calcium caseinate can interfere with the action and effectiveness of some anticonvulsants. Individuals taking these drugs should read labels carefully to avoid foods containing these additives.

Psychotropic medications

Some psychotropic medications, such as amitriptyline, can decrease absorption of the vitamin riboflavin from food. Good food sources of riboflavin include milk and milk products, liver, red meat, poultry, fish, whole grain, and enriched breads and cereals. Riboflavin supplements may also be needed.

Other psychotropic drugs, such as fluvoxamine, sertraline , fesasodone, alprazolam, triazolam , midazolam, carbamazepine , and clonazepam , interact with grapefruit juice, so individuals taking these drugs must take care to avoid grapefruit juice. In some cases, apple juice must be avoided as well. Patients should discuss potential drug interactions with their doctors or pharmacists.

Caffeine-restricted diet

Caffeine is a stimulant and can interfere with the actions of certain medications. As stated, people taking lithium and people recovering from addictions may be asked by their treatment team to monitor (and, in the case of addictions, restrict) their caffeine intake. Foods and beverages high in caffeine include:

chocolate
cocoa mix and powder
chocolate ice cream, milk, and pudding
coffee
cola beverages
tea

Alcohol-restricted diet

Alcohol interacts with some medications used to treat mental disorders. In the case of alcoholism recovery, the negative interaction resulting from the combination of one medication (disulfiram or Antabuse) and alcohol consumption is actually part of treatment for some people. (The medication causes an extremely unpleasant reaction when any alcohol is consumed, reinforcing or rewarding the avoidance of alcohol.)

When individuals are taking medication that requires that they avoid alcohol, foods containing alcohol must be avoided as well as beverage alcohol. The following foods contain small amounts of alcohol:

flavor extracts, such as vanilla, almond, or rum flavorings
cooking wines
candies or cakes prepared or filled with liqueur
apple cider
cider and wine vinegar
commercial eggnog
bernaise or bordelaise sauces
desserts such as crepes suzette or cherries jubilee
teriyaki sauce
fondues

KEY TERMS

Anorexia —Loss of appetite or unwillingness to eat. Can be caused by medications, depression, or many other factors.

Anorexia nervosa —An eating disorder characterized by an intense fear of weight gain accompanied by a distorted perception of one’s own underweight body.

Binge —An excessive amount of food consumed in a short period of time. Usually, while people binge eat, they feel disconnected from reality, and feel unable to stop. The bingeing may temporarily relieve depression or anxiety, but after the binge, they usually feel guilty and depressed.

Bulimia nervosa —An eating disorder characterized by binges in which large amounts of food are consumed, followed by forced vomiting.

Psychotropic drug —Medication that has an effect on the mind, brain, behavior, perceptions, or emotions. Psychotropic medications are used to treat mental illnesses because they affect a patient’s moods and perceptions.

Purge —When a person rids extra food consumed by inducing vomiting, laxative abuse, or excessive exercise.

Relapse —People experience relapses when they reengage in behaviors that are harmful and that they were trying to change or eliminate. Relapse is a common occurrence after treatment for many disorders, including addictions and eating disorders.

Thiamin —A B-vitamin that is essential to normal metabolism and nerve function, and whose absorption is affected by alcoholism.

Tyramine —An intermediate product between the chemicals tyrosine and epinephrine in the body and a substance normally found in many foods. It is found especially in protein-rich foods that have been aged or fermented, pickled, or bacterially contaminated, such as cheese, beer, yeast, wine, and chicken liver.

Resources

BOOKS

Logue, Alexandra. The Psychology of Eating and Drinking. 3rd ed. New York: Routledge, 2004.

Bronner, Felix. Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases. Boca Raton, FL: CRC, 2002.

PERIODICALS

Daubenmier, Jennifer J., and others. “The Contribution of Changes in Diet, Exercise, and Stress Management to Changes in Coronary Risk in Women and Men in the Multisite Cardiac Lifestyle Intervention Program.” Annals of Behavioral Medicine 33.1 (Feb. 2007): 57–68.

Groesz, Lisa M., and Eric Stice. “An Experimental Test of the Effects of Dieting on Bulimic Symptoms: The Impact of Eating Episode Frequency.” Behaviour Research and Therapy 45.1 (Jan. 2007): 49–62.

Hagler, Athena S., and others. “Psychosocial Correlates of Dietary Intake Among Overweight and Obese Men.” American Journal of Health Behavior 31.1 (Jan.-Feb. 2007): 3–12.

Jabs, Jennifer, and Carol M. Devine. “Time Scarcity and Food Choices: An Overview.” Appetite 47.2 (Sept. 2006): 196–204.

Leung, Newman, and Emma Price. “Core Beliefs in Dieters and Eating Disordered Women.” Eating Behaviors 8.1 (Jan. 2007): 65–72.

Mobbs, Charles V., and others. “Low-Carbohydrate Diets Cause Obesity, Low-Carbohydrate Diets Reverse Obesity: A Metabolic Mechanism Resolving the Paradox.” Appetite 48.2 (Mar. 2007): 135–38.

Payne, Martha E., and others. “Vascular Nutritional Correlates of Late-Life Depression.” American Journal of Geriatric Psychiatry 14.9 (Sept. 2006): 787–95.