Nutritional Concerns for the Adolescent Substance Abuser

1. Nutritional Concerns for the Adolescent Substance Abuser Krista Casazza PhD RDN CSSD University of Alabama at Birmingham Department of Pediatrics

2. Glass half full?

3. 2015 • ~11% >12 used illicit drugs • 8% meet DSM V criteria for substance abuse or dependence • 40% concurrent alcohol-drug combo

4. Alabama Substance Abuse facts

5. What’s the Big Deal?

6. BRAIN FACTS Dorsolateral • ~3 pounds • Controls all activities • ~100 billion neurons and 1 trillion supporting cells • Astrocytes • Glial cells • Neurons grow and organize themselves into efficient systems that operate a lifetime • Never stops adapting • Greatest adaptations during early childhood and adolescence • Can re-route circuits • Different regions of the brain regulate different functions. • The prefrontal cortex coordinates higher-order cognitive processes and executive functioning. • Executive functions are a set of supervisory cognitive skills needed for goal-directed behavior, including planning, response inhibition, working memory, and attention • allow an individual to pause long enough to take stock of a situation, assess his or her options, plan a course of action, and execute it. • Poor executive functioning leads to difficulty with planning, attention, using feedback, and mental inflexibility • undermine judgment and decision making. Ventromedial Ventromedial

7. Undergoes significant changes during adolescence — not fully developed until 20’s Frontal Lobe Temporal Lobe Responsible for hearing, understanding speech, and forming an integrated sense of self Responsible for sorting new information and for short term memory Contains the limbic-reward system • Seat of personality, judgment, reasoning, problem solving, and rational decision making • Provides for logic and understanding of consequences • Governs impulsivity, aggression, ability to organize thoughts, and plan for the future • Controls capacity for abstraction, attention, cognitive flexibility, and goal persistence • Prefrontal cortex is one of the last areas of the brain to fully develop (mid 20s)

8. Cognition and emotion are intertwined Limbic System Reward System Drugs of abuse activate the reward system in the limbic area of the brain—producing powerful feelings of pleasure Fool brain into thinking that they are necessary for survival Desire to repeat drug using behavior is strong Drugs of abuse can/do exert powerful control over behavior because they act directly on the more primitive, survival limbic structures— over-ride the frontal cortex in controlling our behavior Underdevelopment of the frontal lobe/prefrontal cortex and the limbic system make adolescents more prone to “behave emotionally or impulsively” Adolescents tend to use an alternative part of the brain– the socio-emotional system rather than the cognitive-control system to process information • Limbic system regulates emotions and motivations—particularly those related to survival—such as fear, anger, and pleasure (sex and eating) • Feelings of pleasure/reward are very powerful and self-sustaining. Pleasurable behaviors activate a circuit of specialized nerve cells in the limbic area that is devoted to producing and regulating pleasure called the reward system

9. You’ve Got Mail…. • All messages are passed to connected neurons through the form of chemicals called neurotransmitters • Neurotransmitters are released from the end of the axon, cross the synapse, and bind to the specific receptors on the dendrites of the targeted neuron • Neurotransmitter • Serotonin and Dopamine – among other things, produces pleasure and desire through the “reward system” and is involved with social information processing. • Norepinephrine • Histamine • Acetylcholine • Re-uptake • Once message delivered, neurotransmitter is broken down and reabsorbed for “recycling”

10. Neurotransmitters and Puberty? • Significant changes in the amount and location of receptors at puberty • Shape social-emotional development • Increases sensation seeking at this period • Decrease of inhibitory control of dopamine release in prefrontal cortex • Increased temporal gap between puberty (change in dopaminergic system) and full maturation of the cognitive control system • Regions activated during exposure to social stimuli overlap with regions sensitive to reward system. • *Note: Social acceptance seems to be processed in ways similar to addictive drugs • Age of experimentation with substances has declined over time, consistent with historical decline in age of pubertal onset. • “Early maturers” at increased risk? • Early maturing youth report higher rates of alcohol and drug use, delinquency, and problem behavior. • Oxytocin – neurotransmitter that is also a gonadal hormone • Significant changes at puberty • Influence on social memory, social information processing, and social bonding • Explains adolescence heightened awareness of other social acceptance contribution

11. Overproduction And Pruning • Brain development occurs in 2 basic stages– growth spurts/overproduction of neurons and pruning • Critical phases: in utero • 0-3 years overproduction • 10-13 years • Overproduction results in significant increase in the number of neurons and synapses • These 3 critical phases are quickly followed by a process in which the brain prunes and organizes its neural pathways

12. Pruning • Pruning • Neural systems that are chronically : • Altering number of synapses & which are pruned • Changing dendritic density & neurotransmitter receptors • Inhibit development of neurons • Change gross structure and volume of the hippocampus • delays in myelination • Inhibition of neurogenesis • Fear response initiates overproduction • HPA axis significantly influences cognitive development as well as behavioral and emotional regulation • Chronic activation of certain parts of the brain involved in the fear response — hypothalamic-pituitary-adrenal-(HPA) axis can “wear out” other parts of the brain such as the hippocampus (memory, cognition, communication)

13. Summary of adolescent Brain Growth Stages

14. Changes occur in the “reward system” that promote dependence • Immediate effect of drug use is an increase in dopamine • Continued use of drugs reduces the brain’s dopamine production. • Because dopamine is part of the reward system, the brain is “fooled” that the drug has survival value for the organism. • The reward system responds with “craving” • Tolerance  Dependence.

15. EFFECTS • the sleep cycle, resulting in impaired learning and memory as well as disrupted release of hormones necessary for growth and maturation. • coordination, emotional control, thinking, decision-making, hand-eye movement, speech, and memory. • perform worse in school, are more likely to fall behind and have an increased risk of social problems, depression, suicidal thoughts and violence. • Significant shrinking of the brain • 50% - 75% show cognitive impairment • Effects remain even after detoxification & abstinence • 2nd-leading cause of adult dementia

16. The Integration of Brain, Behavior and Health

17. Nutrition is important in Substance Abuse Recovery

18. Each drug behaves differently in the body and causes malnutrition and associated disorders in different ways • Alcohol • alcohol generally makes up more than 50 percent of the calories ingested by alcoholics • few who drink regularly eat enough of their calories to get the nutrients they need. • impairs the liver and the pancreas, making it difficult for the body to process toxins out of the system and destroying these two organs. • depletes the body’s stores of vitamins B, A and C • Opiates • slowdown in their gastrointestinal system. • Many have constipation during addiction and then diarrhea when they attempt to stop using their drug of choice during opiate detox. • Any disturbance to the gastrointestinal system means that nutrients are not absorbed properly – even when the addicted patient eats properly, which is rare. • Stimulants • Crack, cocaine, meth amphetamine and stimulants decrease the appetite. • Intentional weight loss. • Unfortunately, not eating enough means not getting enough nutrients or calories for the body’s organ systems to function properly. Just like anorexia, stimulant addiction can kill its victims through malnutrition as the body shuts down. • Marijuana • though more than enough calories are being consumed, they often are poor quality

19. Fig. 2. Frequency of individuals (n = 59) according to each measurement of nutritional risk: (A) the SGA, (B) the Australian Recommended Food Score, (C) the Simplified Nutritional Appetite Questionnaire, and (D) a rating as positive on none, one, two, or all t... Lynda J. Ross, Michael Wilson, Merrilyn Banks, Fiona Rezannah, Mark Daglish Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment Nutrition, Volume 28, Issues 7–8, 2012, 738–743 http://dx.doi.org/10.1016/j.nut.2011.11.003

20. Malnutrition and Substance Abuse • Primary • Food Intake • Displaced • Reduced • Compromised • Secondary • Altered • Absorption • Metabolism • Utilization • Excretion • Health Compromise • Oral • GI- Irritation of the mucous lining of the stomach; circulatory • Circulatory- diuresis • Metabolic • Neurological- decreases motivation & alterations of visual perception • Immune • Relationship between Malnourishment and Illicit Drug Abuse- Largely Unknown • Primary or Secondary • Speculative • Poor Follow-up

21. Methamphetamine • Methamphetamine is a widely abused drug with devastating health effects • increases extracellular concentrations of dopamine, norepinephrine and serotonin by acting on the transporter of each neurotransmitter and by reversing neurotransmitter transport direction • Chronic substance abuse also resulted in significant changes in brain glucose metabolism. • Increases in several areas including primary and higher order somatosensory regions • decreases in the tail of the striatum, hippocampus, and rhinal cortices. • increased metabolic activity in the brain of MA users has been speculated to reflect neuroinflammation and gliosis

22. Glucose normally supplies the vast majority of calories consumed by the brain. • The adult human brain consumes nearly 20% of the human body’s basal metabolic rate • Most of this glucose is oxidized to supply the large amounts of ATP required to maintain membrane ion gradients and other cellular processes related to synaptic transmission • ‘aerobic glycolysis’

23. Nutrition, Substance Abuse and Mental Health • Abnormal Glucose Metabolism • Blunted responses to insulin and glucose • Often associated with high carb intake • Hyperglycemia • Hyperinsulinemia • Rebound hypoglycemia

24. Nutrition, Substance Abuse and Mental Health • Protein Synthesis • Amino acids are the building blocks of neurotransmitters • Serotonin • Dopamine – major chemical in the brain involved in addiction • Also required for neuromuscular control • Norepinephrine • Acetylcholine • Histamine- inflammation • Glycine

25. Fat • Adverse effects on fatty acid metabolism • Low PUFA intake affects membrane fluidity (Bloch and Hannestead, 2012) • Impaired utilization of arachidonic acid for neurotransmitter synthesis • 55-60% of the weight (dry) is lipid • 35% PUFA • Low levels of PUFAs associated with relapse • Inflammatory processes? • Low cholesterol associated with depression and anxiety in substance abusers (Leyse-Walalce, 2008; Carson 2012) • Basal leptin and adiponectin significantly decreased in meth users • Associated with immune dysfunction

26. Impaired Mineral Metabolism • Calcium • Osteopenia • Low levels of reproductive hormones may contribute to impaired bone metabolism • >40% of meth users have dental diseases- “meth mouth” • IV users higher than other substance abuse • Iron • Ferritin down-regulated • Impaired immunity • Increased free radicals (Sun et al, 2011) • In animal models • Selenium and CoQ-10 have been shown to attenuate neurotoxicity of cocaine and meth

27. Nutrition, Substance Abuse and Mental Health • Compromised gut-health • Gastric motility • Essential nutrients profoundly affect CNS at the cellular and tissue level • Brain chemistry • Brain metabolism • Neurotransmitter synthesis and release • Most well-studied • Wernicke’s Syndrome • Thiamin Deficiency • Poor appetite, weakness, irritability, depression • Others • B6 • Impaired protein metabolism, depression • Folate • Fatigue, anemia, depression, poor sleep, poor concentration • B12 • Fatigue, anemia, depression, poor sleep, confusion • Iron • Anemia, fatigue, depression, poor immune response • Vitamin D- ~70% of substance abusers • Joint/bone pain, fatigue, muscle weakness • Zinc • Decreased immunity, fatigue, inflammation • Elevated copper

28. The Role of the RD • Most treatment interventions engage with the psychological, social and spiritual dimensions of addiction • some of the biological/physiologic aspects can at times be neglected. • Dietary imbalances relating to amino acid, vitamins, macronutrients, • accompanied by a host of psychological and behavioral issues. • Nutrition is critical in the recovery process and is often instrumental in securing long-term success

29. Substance Abuse Induces Brain Injury Substance Abuse

30. Nutrition Intervention Goals • Primary goal to support recovery • Nutrition therapy • Weight Management? • Not necessarily the primary outcome • Mental Health Restoration • Emphasis on correction of nutrient deficiencies • Supplementation?

31. Low Carb? • Preferred fuel for brain? • In the brain, insulin promotes cellular uptake of amino acids

32. Low fat?

33. Nourished, now what? • Disruptions in energy metabolism • Change on gene expression? • Impaired protein metabolism, fuel utilization at skeletal muscle (Sun et al, 2011) • Inflammatory response? • Pyruvate pathways diverted to fermentation to lactic acid • Hedonistic reward? • Appetite and taste return in recovery state • Signal pleasure signals reinforced by high sugar and high fat foods (Blumenthal and Gold, 2012) • The more multi-sensory the food, the greater the craving • To achieve “reward” increased consumption • Changes in brain chemistry may induce higher preference for sodium, fat, sugar • First 6 months • Bingeing • First year • Weight concerns • Weight gain • Weight loss • Body Image

34. Addiction Processors?

35. Supplementation • Inflammation • Systemic • Neuro • Increased anti-oxidant needs • Likely increased protein needs • Neurotransmitter synthesis • Skeletal muscle protein synthesis? • GI Motility? • Focus on gut health • May initially conflict with RD “programming” • Neurotransmission • Transmit the “right” message • Food first! • Ideal macronutrient breakdown?

36. What about exercise? • Integration of exercise With nutrition therapy • Whole Body Wellness • Nutrient Delivery and Utilization

37. As a member of the treatment team? • Every patient who walks into a substance abuse program should be assessed by a dietitian • Screen for malnutrition • Request objective nutrition biomarkers • Assess food environment • Educational material

38. Thank you! • Alcoholics Anonymous Manual (1940) • “If we are undernourished, we become irritable and nervous. In this condition our tempers get out of control, our feelings get easily wounded and we get back to the old and dangerous thought processes”