Final Research Project, Bauman College for Holistic Nutrition and Culinary Arts
by Christine Engen
July 18, 2018
Nutrition is a grossly neglected area in traditional recovery programs designed to treat alcohol and other drug abuse and addiction. Research has shown that the majority of addicts suffer from biochemical, nutritional, and metabolic disorders. Traditional outpatient programs focus on the psychological reasons a person abuses alcohol or other drugs; as well, sometimes provide medical support in the form of pharmaceuticals designed to curb cravings and/or block the area of the brain that receives the pleasure signal, so a person won’t abuse the substance. This approach only treats part of the whole. Dr. Charles Gant documented in his book, End Your Addiction Now: “Unless the biochemical imbalances which are the true causes of substance problems are corrected, the benefits of psychological counseling will be marginal for most people.” (Gant, 2002 )
In standard treatment, nutrition is mostly ignored, and the focus is on getting the patient to quit using the substance, mostly through talk therapy. The thought is that so long as the alcoholic or drug addict is not using his/her drug of choice, that he/she may over indulge in sugar as needed and even continue with cigarettes. The problem is, alcohol addiction is a physiological addiction to sugar that needs to be managed during active and long-term recovery. As people withdraw from alcohol, they often replace alcohol with refined sugar and simple carbohydrates and increase coffee intake as part of the withdrawal and maintenance process. (Korn, 2016) The sugar exacerbates cravings … and the cycle continues.
It is a fact that psychological intervention and group support and community are very important parts of recovery and without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM, 2015). I believe equally as important is the fact that if one’s nutrition isn’t corrected, the risk of relapse is high. Most traditional treatment programs do not educate patients on nutrition. They address behavior and emphasize spirituality, mental health and community support, but neglect to educate those with addictions on how to nourish themselves and likewise help prevent the likelihood of a relapse. From a historical perspective, substance abuse is viewed as a mental disorder. However, The American Medical Association and World Health Organization classify it as a physical disease. Rather an “either or”, it may be a combination of each, given the complexity that surrounds addiction. (World Health Organization, 2014)
Definition of Key terms:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. (ASAM, 2012) This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. (ASAM, 2015) The National Institute of Drug Abuse (NIDA) defines addiction as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. (NIDA, 2016)
Dual diagnosis is the co-occurrence of substance abuse and mental illness. For example, alcohol or drugs may temporarily relieve the distress of a person with panic disorder, but ultimately these substances only intensify the symptoms of anxiety and panic. Conversely, over usage of the drug/alcohol itself can cause an anxiety disorder.
Relapse is a process in which the return to substance use results from a series of maladaptive responses to stressors or stimuli. (ASAM, 2015)
Recovery /In Recovery
An alcohol or other drug user who is in "recovery" is essentially in remission from alcoholism. Their alcoholism is not cured, but is at bay in a way that allows them to be free of the cravings and mental obsession, and they have treated their underlying issues (mental health, spiritual, physical) that led to or resulted from their drinking.
Sobriety is the physical abstinence from non-prescribed drugs and alcohol.
Substance Use Disorder (SUD) is abuse of substances, particularly alcohol and other drugs (AOD).
Treatment refers to drug and/or alcohol rehabilitation services.
AOD refers to Alcohol and other Drugs. Alcohol is a drug, and often the two addictions are addressed simultaneously.
Characterization of Addiction – “the ABC’s” (ASAM, 2015)
Genetic factors account for about half the likelihood an individual will develop addiction. However, environmental factors also play a role, so susceptibility is not necessarily destiny. People with mental disorders are at greater risk of drug abuse and addiction than the general population. Regarding dual diagnosis, Dr Leslie Korn has “observed success with the nutritional treatment of addictions by combining two models of mental health nutrition: the model of self-medication and the model of nutrient deficit”. (Korn, 2016) The concept of addiction as self-medication (Khantzian, 1997) suggests that people choose substances to self-regulate painful affective states. The concept is also applied to addiction as nutrient deficit disease (Williams 1998, Hoffer 1962, Pfeiffer 1988 and Enig 2000). If one understands what one is self-medicating, one can identify the nutrients that are missing, and it will complement all other addiction therapies. (Korn, 2016) In years past, Medical Doctors would prioritize having patients quit the drug and then address the underlying mental issues. More recently, it is realized that they both need to be addressed at the same time. Nutritional habits should be addressed at the time of dual diagnosis treatment, for a complete recovery program.
According to Joan Mathews Larson, “most alcoholism treatment in the US is based on the presumption that drinking is a way of dealing with painful emotional and psychological problems, and that once those problems are identified and confronted, the alcoholic will no longer be driven to drink irresponsibly.” Larson reports that a little-known fact is that Bill Wilson, founder of Alcoholics Anonymous in 1935, was actively investigating the biochemical basis of alcoholism with usage of Vitamin B3. (Larson, 1992) Interestingly, this piece of information has been lost in the program over the years, with the emphasis entirely on the Twelve Steps of Recovery (Appendix A).
Another not-well known fact is that the American Medical Association had classified alcoholism as a physical disease in 1957. In 1982, the question of whether alcoholism is a physical or mental disorder was the subject of a major courtroom battle. (U.S. Fourth District Court of Minnesota Decision: Granville House, Inc. Plaintiff vs. Dept. of Health and Human Services, et al, Defendants (Nov 10, 1982) 1-23) Dr Robert Spitzer maintained that “there is no effective psychiatric treatment” for alcoholism. It was ultimately ruled that the disease is predominantly physical as opposed to mental in nature. However, psychological talk therapy continues to be the primary course of treatment, 60 years later.
Following are some of the metabolic imbalances and organ and endocrine relationships and disorders that are contributing factors for addiction and relapse. According to WHO, alcohol is implicated as a risk factor in over 60 health disorders including high blood pressure, stroke, coronary heart disease, liver cirrhosis and various cancers. (WHO, 2000)
ADDICTION IN THE BODY
Malnourishment/malabsorption – Malnutrition may promote drug seeking and impede recovery from substance abuse disorders. (source) Alcoholics exhibit nutritional deficiencies of key amino acids, vitamins (e.g., B-complex and vitamin C), and minerals (e.g., zinc, magnesium, and calcium). (Finnegan, 1989) People in recovery from AOD addictions are often malnourished as a result of substituting AOD for food and by the damage the usage does to the liver detoxification process, as well as the stomach lining and intestinal lining, which affects digestion. Alcohol is an example of a substance that when abused leads to both primary and secondary malnutrition. It is well established that nutrient deficits make one vulnerable to alcohol use and that the ability to digest and absorb nutrients and fatty acids is impaired as a result of chronic alcohol use. (Korn, 2016)
Hypoglycemia Study after study has demonstrated that the vast majority of alcoholics are hypoglycemic. (Larson, 2002) Blood sugar stabilization is crucial to decrease cravings. Evidence supports confusion (addiction transfer) when recovering from SUD between cravings for a substance and cravings for food. Hypoglycemia can cause a wide range of symptoms like anxiety, fatigue, depression and panic attacks, as well as poor adrenal function. “In the alcoholic, whether active or recovered, the prevailing factor is hypoglycemia. All the personality characteristics common to patients with hypoadrenocorticism (weakened adrenals) can be attributed to hypoglycemia. They are aggravated in the addictive drinker and persist even in the (recovered) alcoholic. (Larson, 1992) Dr. John Tintera learned that recovered alcoholics continued to suffer from hypoglycemia, even after many years of sobriety, and determined that controlling it is the most important part of physiological treatment of alcoholics. (Tintera, 1974).
Adrenal Fatigue – Adrenal fatigue is directly related to the hypoglycemia experienced by alcoholics. If the demand of epinephrine (adrenaline) to prevent insulin shock exceeds supply, it can cause emotional instability. (Larson, 2002)
Allergies and food sensitivities – Theron Randolph, M.D., contends that allergies to foods and environmental chemicals cause physical conditions. He has shown that addictions to food and alcohol can produce alternating highs and lows. In his work with AA members, he discovered that many were allergic to sugars, grapes and grains from which alcohol is made. (Randolph and Moss, 1980, Larson, 1992) In another study conducted by Herbert Karolus, MD, 422 alcoholics showed that most were allergic to wheat or rye, the grain bases of many distilled liquors. (Larson, 2002) Clinical Ecologists have also found that exposure to such toxic chemicals as gasoline, cleaning solvents and formaldehyde can cause alcoholic cravings in sensitive individuals. Common environmental chemicals not only set the stage for alcoholism, they can also precipitate relapse. (Larson, 2002)
Other conditions include Leaky Gut Syndrome and Yeast / Candida.
ADDICTION IN THE BRAIN
Nutritional deficiencies can have severe and permanent effects on brain function. Specifically, thiamine deficiencies, often seen in alcoholics, can cause severe neurological problems such as impaired movement and memory loss, seen in Wernicke/Korsakoff syndrome (National Institue on Alcohol Abuse and Alcoholism No. 22 PJ 347 Oct 1993)
Glutamate, a neurotransmitter that influences the reward circuit and the ability to learn, has found to be depleted in alcoholics. (drugabuse.gov). Norepinephrine, epinephrine, serotonin and GABA are also neurotransmitters that exist not only in the brain, but also in the gut. Thus, GI health must always be addressed. In addition, low genetic levels of serotonin and dopamine may predispose individuals to depression and addictions. In The Mood Cure, Julia Ross writes that “depending on whether you’ve inherited deficiencies in serotonin, norepinephrine, endorphin and/or GABA, you’ll be attracted to drugs that affect that particular deficiency zone (or zones). If you don’t correct these underlying biological malfunctions, you can’t fully recover from your addiction”. (Ross, 2002)
Disordered eating, depression, anxiety and other mental health problems can be found in tandem with substance use disorders.
LITERATURE REVIEW AND CASE STUDY DISCUSSION
A number of studies dating back to the 1940’s found that correcting biochemical imbalances with nutrition can have a positive effect on behavior and recovery. (Miller, 2010) I trace the history of studies back to inception as a marker to emphasize how LITTLE has been accomplished in the field of nutrition as it relates to addiction and addiction recovery in the past 78 years and examine current studies emphasis for addiction recovery to demonstrate the focus of current scientific efforts.
In the 1940’s and 1950’s, Roger J Williams published findings on the impact of diet on alcohol consumption in animals. He found that animals, given the choice between alcohol and water, chose alcohol more frequently when they were nutritionally deficient than when they were well fed (Williams, 1956; Williams, 1962, Beasley and Knightly, 1994). Williams also was able to shift alcohol consumption up and down based on deliberately subtracting and adding vitamins to their diet (Williams, 1962). (Miller, 2010)
Between 1935-1945, Dr J. W. Tintera, Dr Abram Hoffer and Dr Broda Barnes conducted studies that indicate addiction is a disease with metabolic causes. They identified metabolic imbalances such as poor adrenal function, low thyroid, low blood sugar and nutritional deficiencies (Finnegan and Gray, 1990)
In 1983, Ruth M Guenther studied alcoholics in a typical AA treatment program and compared it to alcoholics in the same program with an added nutritional component consisting of dietary changes, vitamin and mineral supplements, and nutrition education. She found that six months after discharge, 81% of the study group were not drinking compared to 38% of the control study group (Miller, 2010)
In 1987, Joan Matthews Larson, Ph.D. published findings of a study of 100 alcoholic patients who participated in an experimental 6-week outpatient treatment program concentrating on
biochemical restoration combined with psychotherapy. 85 percent of the people reported
themselves as abstinent and stable 12 and 42 months post treatment. (Miller, 2010) (http://allianceforaddictionsolutions.org/images/pdfs/HRC_Alc_Study_proofed.pdf).
In 1998, Kathleen DesMaisons, Ph.D., created the Biochemical Restoration Program, based on her three-year program working with DUI offenders using diet and nutrition to reduce sugar cravings. People are educated about what foods to avoid, when to eat, and what to eat. She found that people in the control group were charged again for more serious offenses at four times the rate of those in the nutritionally-based program (DesMaisons, 1992, 1998) (Miller, 2010)
In his book End Your Addiction Now (2010), Dr. Gant reports an 83 percent success rate in ending patients' addictions. Gant and his colleagues believe that biochemical imbalances in the body must be attended to before recovery can happen and that alcoholism is primarily a brain chemistry imbalance fueled by a deficiency in certain nutrients. He shows that a critical part of treating addiction is to replenish missing nutrients through food and supplements.
Szydlowski writes in the Abstract Nutrition and Addiction Treatment, 2017, “The research purpose of this study is to review the need and benefits of integrating nutritional support for individual in addiction recovery to support health and ongoing sobriety. The use of food and nutrition principles in the addiction and recovery industry are limited at best.” Research began in 1935 and in April of 2017, it is still “limited at best”! Szydlowski concludes the “appropriate diet approach of alcohol withdrawal can relieve the patient’s discomfort and prevent the development of more serious symptoms. From this review article it is concluded that an alternate diet approach will help the patients with alcoholism to reverse malnutrition, prevent alcoholic related diseases, and reduce craving, thereby establishing a healthy lifestyle”. (Szydlowski SJ, Amato PP 2017)
In 2012, David Wiss founder of Nutrition in Recovery in Los Angeles, CA, writes he has observed an association between diet and depression. Practice experience has shown that dietary improvement can reduce some depressive symptoms. Given that mental illness is a major public health problem, an emerging field known as nutritional psychiatry has received increased attention. (Wiss, 2018). He found that patients with SUDs share characteristics with compulsive overeaters from brain imaging studies and behavioral models. Individuals in early addiction recovery have described dysfunctional eating such as bingeing to satisfy drug cravings, leading to unhealthy and undesirable weight gain. (Wiss, D and Brewerton, T, 2016)
It was a much easier task to find more recent articles and studies on research pertaining to pharmacological solutions for addiction. Blum et al writes regarding dopaminergic neurogenetics: the current research on epigenetics is focused on finding the gene that if eradicated, will eliminate addiction. Following the first association between the dopamine D2 receptor gene polymorphism and severe alcoholism, there has been an explosion of research reports in the psychiatric and behavioral addiction literature and neurogenetics. We are .. beginning to ask the correct questions and we are encouraged by this renewed global quest for answers, so that billions of people caught up in addictive behaviors and process addictions would someday find a way of “redeeming joy” and living a life free of addiction and pain. (Blum et al, 2014)
In a 2016 study, it was concluded Individualized nutrition counseling and comprehensive nutrition education programs provided to the substance abuse population have been found to significantly improve three-month sobriety success rates. Just as patients with diabetes or heart disease receive nutrition education to manage their diseases, patients dealing with substance abuse should have nutrition education that addresses their specific risk factors and increases their chances of recovery. (Arun & Vijayalakshmi et al, 2016)
People are still conditioned to want the quick fix in form of a pill and are looking for the ever-elusive magic bullet. I found that all published research, studies and articles were consistent with regard to the effects of nutrition on an alcoholics pre- and post-recovery health dating back to 1940. My search yielded no contradictory information in terms of whether or not AOD users were nutritionally at risk or contradicting the benefits of nutrition in healing. Issues impeding progress may be that Scientists are chasing a “cure” in the form of a pharmacotherapeutic agent. A recent peer-reviewed article by Juan Canales (2013) states “Research into treatment for problematic stimulant abuse has yet to find a suitable pharmacotherapeutic agent to assist with detoxification, withdrawal and relapse prevention…..The opportunity has now emerged to modulate the dopamine system indirectly through the recently discovered trace amine (TA) receptor system, paving the way to new forms of pharmacological intervention in stimulant addiction.” (Canales, 2013)
Another challenge may be that it’s too difficult for a researcher to follow a person’s exact nutritional habits for a lengthy enough period of time and to be able to directly link it to relapse or recovery. The very nature of practicing good nutrition is similar to the AOD user trying to stay in recovery. For instance, when starting a new eating program, a person is bound to have some “relapse” into old eating patterns. Additionally, the person may struggle with giving up longtime behavioral habits. Slipping into old patterns also will occur occasionally, and with food, it’s not deadly, as it can be with addiction, therefore people may give up the new way of eating once he/she feels better, as the consequences of relapse are much lower.
Enter my client, Dylan, a 27 year old Heroin, Opiod and Alcohol addict 8 months into recovery, who had swapped his addictions for sugar. He’s on a myriad of medications for depression, anxiety and insomnia. He is also on Suboxone for opioid withdrawal. He takes approximately 8 pills a day; none of them are supplements. This was challenging because as a Nutrition Consultant, it is not my role to diagnose or treat Dylan. I also did not want to interfere with what his MD had prescribed, rather I sought to work with his MD on getting Dylan nutritional support not only for his self-described sugar addiction, but also to help him feel better and support his GI system and brain function, in particular. Our #1 priority was to alleviate his sugar cravings. In addition, we sought to increase exercise and begin to introduce calming strategies. We also discussed support for his GI system, as it is linked to his moods as well as to calm his symptoms. We did not discuss any supplementation initially, rather addressed his diet solely with changing the foods he eats. I recommended he get a full blood panel from his MD and for him to let his MD know he was working with me.
NUTRITION AND LIFESTYLE SUPPORT PLAN
The main characteristics of foods for the mainstay of a Nutritional Rehabilitation are S.O.U.L foods, that is, seasonal, organic, unprocessed and locally grown. In addition, these foods should be colorful and diverse. Many nutrients in food are actually pigments (Siple, 2014) so eating a range of colors will give a good mix of phytonutrients, which function as antioxidants and destroy free radicals, tamper inflammation and increase the body’s ability to detoxify harmful substances. Additionally, diversity is important to cover a large variety of nutrients. (Bauman, 2016)
Recommended for recovering alcoholics or drug addicts in the initial phase of rehabilitation is a Cleansing Direction Diet. This way of eating will encompass approximately 20% protein, 30% fat and 50% carbohydrate. After a person has achieved sobriety (abstinence) for 2-4 weeks, then transition can be made to Building Diet, where protein and fat quantities will be increased (Bauman, 2016) or they may consider a Balancing Direction. The Cleansing Direction is recommended initially, due to the fact that alcohol interferes with breakdown of food protein into amino acids and also with how the small intestine and liver process these amino acids. Because of potential digestive issues due to a damaged pancreas that cannot produce digestive enzymes to break down food and make nutrients available for absorption, as well as GI problems with impaired absorption and affected kidney, where the nutrients excreted in urine increase, protein quantity initially will be around 20%. Fats must be from healthy sources such as olives, avocados, almonds. (Siple, 2013). The carbohydrate ration is high, for good reason in early recovery. Having sufficient carbohydrate in the diet may help with abstinence (Siple, 2013). Carbohydrates should be in their whole, unrefined, unprocessed form and include fruit, vegetables and whole grains as well as lots of fiber for a sense of fullness.
Goals for the AOD user in recovery is to follow the cleansing direction and in doing so, replenish vitamins and minerals that most likely are low due to erratic eating habits, appetite changes and even using alcohol as energy calories. Possible mineral and vitamin deficiencies in those who drink include calcium, iron, magnesium, selenium, and zinc. Potential vitamin deficiencies are vitamins A, D, E, and K and the water-soluble B’s and vitamin C. (Wiss 2016)
Helpful for curbing cravings and helping a person with an addiction stay in recovery are the following nutrients, herbs and lifestyle suggestions:
Omega 3 Fatty acids (salmon, flaxseed) increase levels of serotonin, a chemical found in your brain and gut. Serotonin helps to regulate your appetite and mood. Studies have shown that the physical properties of brain cell membranes directly influence neurotransmitter synthesis, signal transmission, uptake of serotonin and other NTs. (Murray & Pizzorno 2012) Supplemental recommendation: 1200-2000 mg (1.2-2.0 grams) of EPA and DHA (Murray and Pizzorno 2012)
B Vitamins (leafy greens, almonds, chicken, liver) curb sugar cravings significantly through the essential support they provide to the metabolism and nervous system. Also help reduce stress. “Correcting folic acid and vitamin B12 deficiencies results in a dramatic improvement in mood” (Murray & Pizzorno 2012) Research suggests that alcoholic cravings are due to a deficiency in B vitamins and that supplements may lessen the desire to drink (Arun, 2016) B12 800 mcg (Murray & Pizzorno 2012)
Magnesium (almond, spinach, avocado, brown rice) is an excellent mood leveler and promotes good sleep, less stress and alleviates cravings.
L-Glutamine (as glutamic acid: almonds, sunflower seeds, free range eggs, free range poultry) is an amino acid. In our brain, it helps create neurotransmitters that enable it to function properly. It also acts as a source of fuel for the digestive system, and a healthy gut is essential in managing cravings. Taking glutamine can keep blood sugar levels steady. “L-Glutamine decreases physiological cravings for alcohol, while also replacing what has been lost of the nutrients in the liver and kidneys as a result of alcohol abuse”. (Szydlowski SJ, Amato PP 2017)
Neurotransmitter Supplements can help rebalance your brain chemistry so that your stress is reduced, treating your sugar cravings from the source. Among the supplements that help calm the brain are L-glutamine, GABA, D-phenylalanine and L-tryptophan. Low serotonin levels can trigger food cravings and bingeing.
Herbs such Milk Thistle (Silymaryin), nettles, fenugreek, ginseng and red clover all help regulate dopamine levels. (Wiss, 2018)
Foods to Avoid:
Sugar, processed foods, trans-fats, processed oils are absolute “no-no’s”. Caffeine should be titrated, and eventually avoided all together (Larson, 1992). Any food that contains alcohol even in trace amounts should be avoided, including kombucha and vanilla.
Other Lifestyle Recommendations:
Natural vitamin D from daily sunlight exposure. If vitamin D is low, the hunger signal is not turned off and cravings can continue even though there has been enough intake.
Avoid blue light at night, it raises blood sugar, influences metabolism, disrupts hormones, can cause insulin resistance, and depression and anxiety. (Owens, 2012)
Epsom Salt Baths with Lavender: Soothing and calming, to ease anxiety and depression and promote sleep.
Meditation: Mindfulness leads to decreased anxiety and stress.
Exercise – Move every day, at least 30 minutes for natural endorphins, flexibility and increased metabolism.
There is ample research proving the negative effects of substance abuse on the body and on the brain, among many are malnutrition, malabsorption, damage to major organs, GI problems and neurological and emotional disorders. However, despite all the information proving that alcohol damages the body and the brain, treatment for substance abuse disorders is almost completely psychological and pharmaceutical. This research project was challenging in the sense that there were very few recent studies done on the effects of nutrition on recovering alcoholics and addicts. The American Society of Addiction Medicine (ASAM) states only about 10 percent of individuals who join a 12-Step program recover. I remember sitting in group therapy at Kaiser Permanente’s Chemical Dependency Intensive Recovery Program, and the moderator asked us to look around and realize that out of the 20 of us, only 2 would make it. In that course, nutrition was covered in one session for 30 minutes and it was completely outdated, using the USDA My Plate as the guide for how alcoholics in recovery should be eating. No wonder long term sobriety is attained by a mere 20-25% of people in treatment, at best. A study conducted by AA in 2014 showed that 27 percent of the more than 6,000 who participated in the study were sober for less than a year. In addition, 24 percent of the participants were sober 1-5 years while 13 percent were sober 5-10 years. Fourteen percent of the participants were sober 10-20 years, and 22 percent were sober for 20 or more years.
My research into literature, articles and studies yielded consistent, yet sparse results. One in ten people struggle with alcohol or other drugs. According to the 2015 NSDUH, 15.1 million adults ages 18 and older (6.2 percent of this age group) had Alcohol Use Disorders. There were approximately 20.6 million people in the United States over the age of 12 with an addiction in 2015. I believe that holistic nutrition can not only help people get sober, but it can help keep them in recovery. I believe the very act of caring for self is protective and recovery related. Paying attention to how one nourishes one’s body is the ultimate act of self-care. When we were children, our parents fed and nurtured us. We must learn to take care of ourselves the way they did, or the way we wish they did. Self-love is a big part of recovery, along with forgiveness of self and eradication of guilt and shame. Psychological programs and community support such as Alcoholics Anonymous, Narcotics Anonymous, and SMART Recovery are all thorough programs that address the mental, spiritual and community needed for a person to stay in recovery. Holistic Nutrition must be included as an equal part of all recovery programs, so the physical is connected to the mental and spiritual components, for a well-rounded recovery.