Dietitian Rehab

#007 Nutrition for Addiction & Recovery

Podcast artwork 300x300 - #007 Nutrition for Addiction & Recovery

Detoxing from dogmatic dietitian education and attitudes for a mind wide open

But first, “you must unlearn what you have learned” YODA

Traditional recovery therapy has focused on normalizing eating, behavioral aspects of using, and modifying triggers. While these play a part, they don’t consider the entire dimension of wellness. Nutrition in Recovery bridges the gap between nutrition and mental health by considering the impact that food has on the brain, the gut, and the endocrine system while incorporating psycho-social and behavior change.

More about David Wiss

David Wiss, MS, RDN, CPT, grew up in Los Angeles, graduating from the University of Southern California with a Bachelor’s Degree in Social Science. He earned a Master’s Degree in Nutrition and Dietetics at California State University, Northridge, and completed training to become a Registered Dietitian Nutritionist (RDN).

 

His Master’s Thesis “Nutrition and Substance Abuse” was a multisite and multidisciplinary investigation into the special needs of addicts and alcoholics within the Veterans Affairs Healthcare System.

 

Currently, David Wiss is working on his Ph.D. in Public Health from the University of California, Los Angeles with research focused on nutrition and addiction.

 

Prompted by his extensive research and inspiring case studies, David Wiss discovered that nutrition is a poorly understood and frequently ignored component of treatment during rehabilitation from substance abuse. In 2012, Mr. Wiss founded Nutrition in Recovery and developed a detailed curriculum that provides specialized nutrition services to individuals and treatment centers.

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Read the transcript

Doug Cook:

Welcome to the Dietitian Rehab podcast where we not only challenge and inspire dietitians to think outside the traditional dogmatic education, training and attitudes for a mind wide open but also to challenge anyone to think differently about your own health. We’ll talk all things food, health and nutrition related as we explore points of view, evidence and strategies for better health that will allow you a fuller understanding of the hot topics that everybody’s talking and asking about.

 

Hey, everyone. Welcome to the show. I am your host, Doug Cook and today we have a fantastic interview with David Wiss. David is the founder of Nutrition in Recovery, a service provider of nutrition therapy for addiction and eating disorder recovery in LA with a focus on both the physical and nutritional wellness as primary components of recovery. Nutrition in Recovery aims to bridge the gap between nutrition and mental health by considering the impact that food has on the brain, the gut and the endocrine system. By informing and encouraging behavior change with respect to food, David and his team help to contribute to positive long-term recovery outcomes. So, let’s get to it. Great. Well, welcome to the show David.

 

David Wiss:

Thank you so much for having me.

 

Doug Cook:

I think this topic will be a huge interest to a whole bunch of different people not just dietitians and other health professionals but members of the general population or public I guess who are interested in the topic generally who may know somebody who has an eating disorder or substance use disorder and maybe they’re even just thinking about their own issues. So, I remember I think stumbling upon your work because I was just doing general Google searches for nutrition and addiction and that kind of thing. So, at least in Canada, we don’t really have people specializing or niche in nutrition and addictions. So, I work in a public health hospital here. It’s Canada’s largest psychiatric and addictions hospital and we do have a quasi-recovery program and detox unit. So, that’s where my interest got into this but I realized a lot of people are just not that well versed in it beyond some of the kind of general nutrition stuff that we’ll talk about. So, just by way of introduction, I hope I have this right, I would consider you the founder of Nutrition In Recovery, a service provider which is really a private practice. There’s a group of four of you providing nutrition therapy for addiction and eating disorder recovery in LA and it’s dedicated to the promotion of both physical and nutritional wellness as the primary components of recovery. So, before we dive into that, I’m wondering if you could talk a little bit about yourself, specifically your personal/professional journey and how you got to where you are specifically with this area of practice. And I think there’s probably some value if you want to blend in or talk about both your Master’s thesis looking at nutrition and substance abuse and you’re currently doing your PhD with a focus on nutrition addiction. So, I’ll that you decide what would be of interest to people.

 

David Wiss:

Yeah. Thank you for that introduction. I’m always excited to talk about things that are cutting edge and new and I think the broad field of nutrition for mental health is definitely that. So, I’m excited to go there with you today. I am from Los Angeles originally so growing up in LA was certainly exposed to a fair amount of mental health challenges, eating disorders, addictions in personal life, social networks, families, etc. So, I originally came into nutrition through the fitness lane. It’s a sort of a socially constructed thing. I was a trainer for a little while early in my 20s and I assumed that if I was going to be in nutrition, that was the direction that I was going to go. It was almost like there were lanes. If you’re going to do nutrition, you can do be in this lane, this lane or this lane. And I really thought maybe that was the right lane for me.

 

When I started studying nutrition as a Master’s degree at Cal State Northridge, I really wanted to do more with my life and career. I felt like there was untapped areas of nutrition that people weren’t kind of moving towards. So, substance use disorder always caught my attention. In LA, there’s a huge private sector for addiction treatment. In 2012/2013, some of the insurance game changed and there was really an explosion of private sector treatment and this was right around the time that I was finishing up my Master’s degree. I wanted to do a thesis looking at nutrition for substance abuse. So, I collected some data at the VA. It was really my first exposure to hands-on research. It was just a survey study. The findings weren’t super salient. We found that people that had a history of substance use disorder had a harder time managing their eating behavior when they were depressed.

 

So, I really learned that nutrition for mental health wasn’t being discussed at least in 2012/2013. So, part of my thesis was to review all the literature linking nutrition to addiction recovery and I learned a lot. However, I learned that the literature was extremely limited. In other words, the data that did exist was just focused on certain micronutrient deficiencies, things that are measurable, things that are easily captured by either blood data or survey data. So, I saw that there were some real gaps. There were only a few studies published at that time and still to this day that described nutrition interventions for addiction recovery. In other words, in a residential treatment center or a sober-living where there was actually either one nutrition education changes in food service, actual implementation of nutritional guidelines and/or individual counseling or in some cases exercise-based interventions. So, that was pretty much undescribed.

 

So, I had a vision early on that I wanted to contribute to this literature. Perhaps at some point, the idea of nutrition for addiction recovery could have enough evidence to where it would be supported by the insurance model. Right? To date, it is still not but with my doctoral research and some of the things I’ve been working on, I do identify that as being one of my primary long-term goals to be able to get nutrition services recognized for mental health. Obviously, there are dietitians in eating disorder treatment centers and in certain long-term care but in addiction treatment, it does not exist. So, in doing all my kind of basic literature reviews and preparation for my Master’s thesis, I learned a lot. I saw the gaps and since that time, I’ve been working really hard to fill some of those gaps conceptually and make contributions to this space. So, my current professional life consists of doing one-on-one counseling with people. My team, we run groups at a lot of addiction facilities. We run nutrition groups using curriculum that I’ve created and then I’m split the other half doing research and writing manuscripts and doing my doctoral study. So, it’s a really great blend.

 

The last thing I’ll say is that in doing my literature review, I learned that there’s a broader field of nutrition for mental health. I often use the term behavioral health and that includes eating disorders, anxiety, depression and all of those things often cluster and co-occur. So, I’m of the belief system that in order to work with substance use disorder, one has to also understand disordered eating as well as some of the other commonly occurring mental health things. And in recent years, all the kind of data has pointed towards the gut/brain access, right? So, that’s where a lot of the nutrition interventions can actually make an impact. If the gut is informing the brain and the brain is informing the gut, there’s a target for intervention and I think nutritionists need to be savvy with this information so we can be on the cutting edge of intervening in the nutrition for mental health space. The term that I see used often is nutritional psychiatry which kind of suggests that it’s more psychiatry than nutrition. But as nutritionists, we need to get on that train.

 

Doug Cook:

Yeah. My head’s spinning because there’s so much that you’ve just talked about that highlights a lot of gaps regardless of the healthcare system. So, something that I just need to clarify for myself when you were speaking there, so you were saying—I know in the U.S. you have insurers and then you code diseases and then based on the coding, the hospital gets reimbursed. That’s a crude summary based on my limited understanding. So, did you say addiction is not currently seen or codable as a mental health issue? Is that what I heard?

 

David Wiss:

No. I think what I was getting at is that in the addiction treatment formula, there are tons of services that are required in terms of therapy, psychiatry, group facilitation. There’s a prescribed formula for treatment and nutrition is not part of that formula. In other words, if an addiction treatment center wants to use a dietitian, they are going to have to do it out of pocket. It’s not something that the insurance company is going to say we’re going to reimburse you for those things.

 

Doug Cook:

For the services for the dietitian.

 

David Wiss:

Yes. So, if a place doesn’t believe in it, then they’re likely not going to do it because it’s a cost center rather than anything else.

 

Doug Cook:

Got it. Yeah. So, a) that’s unbelievable given the mountains of research on nutrition even if you take a reductive approach and look at something like magnesium that can help with depression. If someone’s deficient magnesium, that’s a really simple example. So, a) that’s boggling but then I guess the corollary for Canada is just trying to get mental health funding dollars because it all goes to the sexy stuff like cardiology and surgery and all that kind of stuff. So, it sounds like it’s an issue regardless of where we are. I don’t know what it’s like in Europe or Australia or that kind of thing. So, yeah. So, I find that mind-boggling given the role of nutrition just in mental health and recovery even if it’s at the most basic level like addressing protein energy malnutrition. So, I just have a couple of questions to kind of review for the listeners that will help them maybe understand this in a way that if they’re not a nutrition professional. So, I’ve only been working in mental health specifically for eight years. So, when you look at mental health, you talked a little bit about this, when you look at traditional nutrition therapy, what has been the approach? And whatever that approach is, are there problems with it and what are the limitations to the approach? Because I have my own ideas based on my own experience but I’m really interested in yours.

 

David Wiss:

Yeah. There’s an effort to make our work as scientific as possible and science often involves math and math is measurable. So, there’s a strong bias toward looking at things that are measurable, right? And so, things that are measurable include calories, macronutrients, micronutrients from blood or from the food itself and the assumption that nutrition can be turned into a big math problem is, like I said, sound and scientific to some extent but the application of it outside of, for example, a hospital setting is very challenging. In other words, if someone is literally being monitored by an entire healthcare team and you want to correct nutritional deficiencies with supplements and you’re able to watch everything, someone intakes, that makes a lot of sense which is why it can often be referred to as medical nutrition therapy. But if someone is living in the world, the ability to turn nutrition into a big math problem, it has limitations, right? For one, there are some people that can do it. Say okay, I need X amount of milligrams of this and I need to hit these kind of target things and there are apps that make it easy for people. But in behavioral health, when people have altered neuro chemistry, there are disordered behaviors, there’s high susceptibility to extremes, the application of that in an outpatient setting or even at a sober-living is not only challenging but it can actually move people in potentially negative directions.

 

So, I’ve always thought that just looking at nutrition as grams, milligrams, calories is super idealistic and focuses so much on the biochemical aspect of it, the kind of reductionistic biomedical approach and gives no acknowledgment of what I like to call eating behavior, right? Appetite, reward, emotional eating, etc. So, I think that making an assumption that the reason people don’t eat the way that maybe they should as prescribed by medical nutrition therapy is because they don’t know is a faulty assumption. The reality is people are driven to eat based on factors that are not easily captured by the mathematical kind of stuff. For example, neuroscience, right? Gut bacteria, all of these other hormones, things that we’re not measuring. So, I think that we could do better looking at nutrition for mental health more broad, right? So, not just what we eat but when we eat. I like to think about how we eat. Some people are rapid consumers. Another important part of nutrition for mental health is what percentage of the day do people spend thinking about food and body, right? So, someone has to spend 90% of their day to use an app to make nutrition work a certain way and they’re socially impaired, that could create another mental health problem. So, those are all things that are not often addressed and discuss that I like to bring to the light to think about nutrition as more than just a math equation.

 

Doug Cook:

Yeah. And that the whole app thing, I mean that’s a new phenomenon but it can lead to some disordered eating. I’m not using the very language but it can certainly affect people’s cognition around food which in and of itself is a whole another issue. For sure, there’s a huge gap at least in our training on this side of the border where we’re not taught any of this stuff. It’s always something you do after your internship and once you start practicing if you want to take continuing education courses in this kind of counseling around behavior, what you’re eating, how fast you’re eating, the stuff that you’re talking about which I mean admittedly I’ve never really considered as well. I’ve really been focused on the grams and that type of thing. Yeah. And I think for me, what I’m just wondering about some of the limitations is some position papers out there and it really is general healthy eating which is a reality, like a real legitimate focus for people who might be eating really terribly getting some really basic education in there as well, talking about budget, eating on a budget and food security issues. But even that can only go so far I think.

 

David Wiss:

Yeah. One other point about the mathematical and app based approach is that it can really send someone a confusing message if the outcome of interest, for example, is calories, right? Someone might truly get a sense that let’s just call it a hundred calorie pack of some kind of cookie that has an artificial sweetener in it, right? A low carb cookie. Some diet food per se that has a hundred calories would be a better choice than 150 calories container of big thing of raspberries or something of that nature. When calories become the focus, I think people lose sight that there’s more to food than calories. That it’s profound information that one sends to their gut. So, someone might choose the diet drink over the regular drink because of calories but I don’t know. Maybe artificial sweeteners might be problematic for certain people, etc. So, it’s my kind of go to message lately is that there’s more than meets the eye and there’s more than we’re currently measuring.

 

Doug Cook:

Yeah. No, that makes perfect sense for sure. The segue I guess to that would be since there’s all this overlap between mental health substance use disorder and eating disorders, how has nutrition been typically leveraged when addressing substance use disorders? Because I know how it’s done in the hospital when you’ve got these like inpatients that stay five to ten days for detox and I always say it’s a quasi-treatment. It’s not a full treatment. We had a quasi-rehab and it was a three week program. Yeah. So, how’s it been used or applied nutrition therapy specifically for substance use disorder? There may be a lot of overlap.

 

David Wiss:

Yeah. So, I think it’s safe to say that my original vision included bringing nutrition education and counseling to individuals that had substance use disorders and typically drug addiction and alcohol, pill prescription abuse, etc. is associated with really poor eating patterns. So, we’re looking at typically less than 10 grams of fiber per day, a lot of food from added sugars. It’s basically a condition where the gut is not very, let’s just call it strong, active. And so, my original assumption was that it’s just going to be about teaching people how to eat more healthfully and what I came to find out is that there are a lot of people that have body image issues and disordered eating that is actually driving substance use. So, a lot of people gravitate toward stimulants and things of that nature because of the sense of thinness or loss of appetite. That’s actually a pretty strong thing not for everyone but the overlap between eating disorders and substance use disorders is anywhere from as low as 3% up to 50% in all the published studies. So, the question has always been which one is first. So, which one’s primary and which one’s secondary? Because in some cases people have underlying body image issues, they have reward dysfunction, maybe they were secretively eating or binging as a kid and then they found drugs and alcohol and that whole kind of dysfunctional disordered eating stuff went away. And then when they get sober, it all starts to come back. So, there’s typically loss of control eating, body image issues start to show up, people have interest in dieting, etc.

 

So, it’s a really challenging art to be able to know that each individual is different. So, for example, one person might need just really clear like get your nutritional act together, fiber, omega-3, let’s get you on protein, let’s get you eating real food and it’s going to reduce the inflammation in your body and over time improve mental health most likely whereas the next person might have a long history of dieting and have extreme levels of body dissatisfaction that they’ve never talked about, etc. So, the message of let’s just eat healthfully might actually be moving someone in a more extreme direction that we might want to avoid. So, running nutrition groups in addiction treatment settings is very challenging because people are at different levels of education and they have different levels of disorder dysfunction and body image disturbance, different drivers per se. So, I’m always of the belief system that nutrition should be assessed on an individual basis and whenever I do one-on-one counseling with people in substance use disorder recovery, it’s really important to screen for eating disorders, food addictions, to look at other potential drivers. Ideally, we would screen for adverse childhood experiences. If people have trauma and PTSD, there’s a strong link there to disordered eating and addiction like behaviors, etc.

 

So, there isn’t a kind of formula and I believe that the dietitian working in this population needs to know about gut health and needs to know about eating disorders and body image in order to do what’s most important as a dietician for me which is do no harm. So, two people that come through my office, they might even be at the same treatment center, they might need to get totally different messaging around nutrition and that’s where I think a lot of people run into challenges especially dieticians. A lot of people want to adopt a food philosophy. It’s like this is where I stand on nutrition. This is my belief system. This is my philosophy. Therefore, everyone who comes to me who’s going to get my philosophy and I just think that that can be really problematic. I think that that approach is much easier on the practitioner than it is on the client. Say someone says like no, I’m about eating real food. The next person’s like I believe in intuitive eating. It’s like you have your model and then you try to make people fit into your model rather than understanding that this person might really, really need strong encouragement to eat less junk food and eat more real food and the next person, they’re totally orthorexic and they’re super concerned about everything they eat and they need a different message maybe to start including some of the things that they’re more fearful of to get more peace with food and body. So, that’s a broad overview of behavioral health nutrition.

 

With regard to specific guidelines for substance use disorder, I have published in recent years, there’s a book chapter where I reviewed all the evidence for specific substances in an effort to break down what things should be considered for opioids, for stimulants, for alcohol, etc. Now, it kind of goes against what I just said that there isn’t one approach but people want that. People want to know what’s the heroin diet, what’s the alcohol diet. And so, there’s information there and they’re not that different but, for example, alcohol might impair gut function more than cocaine literally from the impact of the alcohol on gut bacteria. But there’s so much so we don’t know. There’s just so much that we don’t know about substances and nutrition. So, hopefully, we will know more in upcoming years.

 

Doug Cook:

Well, and in fairness to you, there’s going to be enough overlap I think that if someone comes in, they have a history of alcoholism or severe alcohol use disorder that you can be confident that there’s going to be certain things that they’re dealing with from a nutrition point of view. So, there’s going to be enough consensus or agreement across those populations or those patient populations or those types of drug use that there’s going to be validity in some of those kind of broad stroke approaches.

 

David Wiss:

Agreed.

 

Doug Cook:

And again, I may be splitting hairs for people. So, when it comes to eating disorders, can you talk about what nutrition therapy has typically looked like? I mean we can kind of just focus on restrictive eating like anorexia and/or bulimia even though there’s a whole spectrum in between. I have a couple of questions that I’ll ask and maybe you’ll answer them as you answer this question that at least the eating disorder centers here in Toronto that I’m aware of, I find their approach bizarre to say that kindly I guess in light of what you just said previously to this about this approach, how we should be approaching people on an individual basis. Anyway, that’s the long introduction to the question. So, how has nutrition therapy typically been used for eating disorders?

 

David Wiss:

Yeah. That’s such a great question. One of my favorite things to talk about. The development of the eating disorder model came before the DSM-5 where binge eating disorder was a standalone diagnosis. So, traditionally, when people think eating disorder, they think anorexia and bulimia and those are the more classic types of eating disorders. One of the main theories in the psychological and therapeutic space around eating disorders is known as the trans diagnostic theory of eating disorders which suggests that the diagnosis itself is not consequential or doesn’t really matter in terms of the treatment and the outcome. So, there’s an assumption that whether it’s anorexia or bulimia even though there’s some different behavioral manifestations, the therapy can be similar, addressing underlying issues, relational issues, attachment. More recently people are focusing more on trauma with certain types of restrictive eating disorders. There’s often OCD, perfectionism, other kind of predictable clusters of mental health presentations. But that model has been kind of adapted by I think the nutrition model which assumes that the nutrition intervention doesn’t really matter in terms of what the eating disorder diagnosis is.

 

Now one thing that I’ve learned because I’ve been somewhat critical of nutrition and eating disorder treatment over the years, one thing that I’ve really learned which is humbling and true is that if someone is trying to operate a treatment center, you need to have a model. You can’t have this idealistic thing that I’m describing where it’s like needs are assessed on an individual basis and this person is going to get this message and this person is going to get this message. This person is going to learn how to eat more chocolate cake because they’re so afraid of it and they need to do it therapeutically and this person’s only been eating chocolate cake and needs to learn how to eat less of it and eat more of other things. That is what I’m saying can be done in an outpatient level but it’s much harder to do if you’ve got 20 people all in a [inaudible 00:29:04]. You almost have to have a food philosophy in an eating disorder treatment center. Otherwise, it’s burdensome on the staff to be able to know that different people are being treated in different ways.

 

So, what it lends itself to is a food philosophy and the predominant food philosophy and eating disorder treatment is all foods fit and that there’s no bad foods. And I think that has come under a lot of criticism and scrutiny in recent years because it just assumes, it makes a really strong assumption that everyone that has an eating disorder, their entire driver is restriction and restraint and that the only thing kind of causing the disordered eating is their restrictive tendencies and I just know that since binge eating disorder has been a more recently recognized, eating disorder, there are people that have bulimia that are trauma survivors that don’t really fit that assumption so well. And so, traditionally, eating disorder treatment has been geared toward the restrictive eater but I think that there are a lot more eating disorder presentations that don’t exactly fit the pure restriction model and have more links to reward based eating stemming from trauma and stemming from substance use disorders that doesn’t fit that great into the model.

 

So, in summary, the eating disorder treatment world has been dominated by the mental health psychological perspective of make peace with food cognitively and there hasn’t been a lot of efforts to discern some of the biological stuff so being able to think about someone’s neural chemistry or their levels of intestinal permeability, some of the other inflammatory markers. The stuff that might be going on biologically that’s linked to the disorder and the dysfunction has been entirely ignored and when people are presenting with some of these issues, they kind of get the message of it’s all in your head. Just eat the chips and we’ll process it afterwards. And a lot of eating disorder clients are like this doesn’t make sense to me and they never want to go to eating disorder treatment again. So, I think that the model that exists is perfect for some clients. It’s just not a catch-all for all people that have disordered eating. So, I see a future where there’ll be a broader net for disordered eating.

 

Doug Cook:

Yeah. And so, you answered my question because I have a friend who has anorexia nervosa and she has been admitted twice to a program here and I don’t even know if they were all restrictive or to your point, I don’t know if it was a bit of a mixed patient profile or population. But I found it interesting because the idea for people who might not understand some of the lingo. So, she had a BMI of 14 which is basically emaciated. I don’t know what calorie count that would correspond to to maintain that low body weight. It could be 1,400 calories. Who knows? And then if we want some of the so-called healthy BMI of 22, that might correspond to say for an example 2,400 calories. So, the program over six weeks or whatever is designed to incrementally increase their caloric intake to match a higher calorie intake to maintain a so-called desired weight goal. So, they get a menu and they get to choose these foods and there’s rules around how many options they’re allowed.

 

So, some of them are non-negotiable like you have to have a protein of veg and then there’s some flexibility around the dessert. In between that, there are three Ensure Boosts which are basically milkshakes. And then—I’m not a desert eater. Like I would rather have French fries and salt. I’m not a sweet person. I look at a piece of cake and it does nothing for me. But they have to eat the banana bread as a snack or a cake even if they’re not into that just to quote normalize eating. And so, I just found that odd because I mean she’s been there twice and it hasn’t really changed much but I guess that’s to your point. And then the idea is that that is quote normalizing the eating because you’re not looking at the banana as a bad food and smoothies, for example, would be seen as a form of disordered eating because you don’t drink food, you eat food which of course is preposterous. It could be for some people. Most of my breakfasts are smoothies so I don’t know if that means I’ve got an eating disorder in my head and it’s like it goes in my thermos or whatever and I take it to work. So, I just found that really bizarre so I was really interested to see what you had to say about that.

 

David Wiss:

Yeah. And like I said, to the credit of the eating disorder treatment center, they have to have company-wide rules and they’re based on assumptions. So, they’re going to assume that people are scared of desserts and they’re going to assume that people aren’t getting enough calories. So, their model is based on matching a certain type of anorexic whereas that might seem ludicrous to someone else. I remember there was an eating disorder treatment center where they didn’t let you eat salads because salads are typically the most low calorie restrictive food that anorexics will choose often or bulimics. And I remember that there was a binge eating disorder client who was just eating fast food for months and came in there and wasn’t allowed to eat a salad and they were trying to get their thing together. I remember the person was so confused and it makes sense to me why a treatment center has to have a model and they also are providing food. So, they are buying food. So, they’re a food service operation as well. So, I’m critical and I criticize but I’ve also learned that they have to have food that they order that they have on hand and they’re trying to do the best they can with the model that they know and I just think it could be done much better.

 

Doug Cook:

Yeah. So, to me, you’re highlighting a ton of missed opportunities for improving this. And just going back to what you just said, like we tell people to eat fruits and vegetables because they’re healthy and then there is that for some people it could be problematic. I guess it does have to be tailored somewhat. But yeah, to me that’s too restrictive. That just seems weird. The thing that gets me really excited, my focus and I know this is not a holistic approach, is I really do get into, it literally turns my crank if you will, is the biology, the physiology, the biochemistry and of course, is behavioral and psychological considerations just like you mentioned. But you’ve touched about the physical aspect of the physical part of the body that does play a role in well-being in mental health. And so, it’s new I guess because no one’s really bought into it but there’s tons of research looking at gut health, looking at the microbiome. And for people who don’t know this, the gut-brain connection, so you got the brain and you’ve got the gut and then maybe I should be letting you talk and outside of the brain, the next largest concentration of neurons is in the small intestine and I guess part of the large intestine. And they’re constantly talking to each other along the vagus nerve up the spine and through neurotransmitters and stuff. I always say you can’t have the health of one at the expense of the other. So, I’ve always kind of when I was doing private practice, that’s why I called myself the gut-brain person because to me, they’re inextricably linked and you can’t just talk about mental health without thinking about the guts. So, in a fantasy world maybe, this would be a better question, how would you like to see all of this be combined in a treatment model?

 

David Wiss:

Yeah. Thank you for that. I think that change is happening. One of the big breakthroughs in the last seven or eight years was the discovery, as you mentioned, that many of the neurotransmitters essential for mental wellness are produced in the gut. So, everyone’s heard the numbers cited over and over again, 80% to 90% of serotonin has an intestinal source, roughly 50% of dopamine is produced in the gut. So, if, for example, we have someone in treatment whether it be a substance use disorder or an eating disorder or even a mental health mood disorder, depressive symptoms, anxiety, if someone is getting medication to work on their brain, to work on neurotransmitters, medications don’t make new neurotransmitters. They ideally make them work better. And there’s no attention to what’s happening at the gastrointestinal level. It’s a total, like you used the term, missed opportunity to optimize someone’s health and well-being. So, the first piece that really is opening up this idea of nutrition matters is the idea of post biotics. So, probiotics are the bacteria themselves, prebiotics are the fibers that the bacteria decompose and thrive on and then this new term that’s emerging is post biotics which is all of the different compounds that are produced by the bacteria that are sent through the intestinal lining into our blood and travel to various organ systems.

 

So, there are neurotransmitters. Another hot area is short chain fatty-acids and some of these compounds can become precursors for hormones, some of them are associated with anti-inflammatory properties at different parts of the body particularly in the colon. I know butyrate supplementation has become a popular thing in the last year or two for gastrointestinal issues that people aren’t producing enough butyrate then there’s some problems. Where I’ve become most interested is in the inflammasome, the different potential inflammatory conditions that are created at the gastrointestinal level and more specifically how those can accumulate over time starting with just low-grade systemic chronic inflammation and how that over long periods of time can affect mental health. So, it’s a really hot emerging area. For example, if someone has a long history of alcohol, we used to assume that the ethanol itself turns into acetaldehyde and might be damaging to the liver. We now know that that model is incomplete. It’s the ethanol’s effect on gut bacteria leading to dysbiosis which increases inflammatory states in the gut, increases gut permeability often referred to as leaky gut. Little particles whether it be bacterial, cell walls, LPS, etc. can leak into the blood and then over time the particles end up going to the liver and the immune system is trying to fight it at the liver. So, the direct effect of alcohol an alcoholic liver disease is not direct from ethanol to liver. Its ethanol to gut, gut inflammation to liver. Now that’s one organ system.

 

In recent years, there’s been a lot of attention to the blood-brain barrier. With now all these neurodegenerative diseases, it’s been shown that cytokines which are inflammatory markers can actually pass the blood-brain barrier. So, and alcohol model, it’s been proposed that the inflammation occurring at the gut can travel to the brain. So, this is referred to as neuro inflammation. For example, there’s some evidence to suggest that the amygdala which is responsible for emotions, anxiety, depression, craving, etc. can become inflamed. So, for example, if someone has a long history of alcohol and they have gut leakiness and they have inflammation that’s been kicking off for many years and now they present to treatment with anxiety and depression and the root cause of their recovery related mood disorders are gut leakiness and then they get treated with a psychiatric medication that’s not necessarily addressing inflammation, it might lead to more negative outcomes than positive outcomes.

 

Now I’m not anti-medication at all. I just feel like I have a responsibility to educate people on this newest latest science. Oftentimes, we’re quick to prescribe medications and we’re not quick enough to look at nutrition and to look at the gut. And in the last two or so years, there’s been about a dozen papers that have shown a lot of medications particularly antidepressants do have strong negative effects on the gut so reducing bacterial diversity, increasing inflammation at different parts of the GI tract. So, I’m really concerned that we are over medicating and underutilizing nutrition services. And the reason why that’s true is multifactorial. One is like we said before, the insurance model supports that and not that. So, that’s what people are going to get.

 

But also it’s really important to recognize that people come into recovery and people come into hospitals and treatment centers in crises and are looking for fast solutions and nutrition is not a fast solution. It is not something that like oh, let’s change the way you eat and you’ll feel better in a day or a week. It’s something that takes months and years. So, it’s not an easily measurable intervention that we can associate with a short-term outcome and it’s harder for to get people to buy into it when it’s kind of like no, you’re going to have to eat differently for several months before you’re going to like kick start a revolution in terms of repopulating your gut with beneficial bacteria, producing short chain fatty acids, reducing inflammation, healing your gut. That’s a long arduous process and it’s very, very difficult for behavior change. So, when I tell people that, they appreciate it because you’re being forthcoming. It’s like nutrition is not a like a short-term intervention that you’re going to feel great after a day or week. Some people do by the way but it’s something that’s going to affect you over your life course and the time to start making changes is now.

 

Doug Cook:

Yeah. No, I mean everything you were just talking about is the stuff that gets me out of bed and excited to read papers and that kind of stuff because it’s just to me, every time I read it, I’m still blown away and in awe of this connectedness throughout the body and the real impact and how it’s downplayed. And I guess my perspective is still in healthcare, there’s this idea of nutrition and the early days was about preventing deficiencies. And so, just getting the bare minimum to do that and then I think we’ve forgotten that it’s more because the body’s, as I always say, I don’t know if it makes sense, is that the body’s made up of elements, the same stuff that the stars and the planets are made of, hydrogen, oxygen, carbon, whatever, we get that from food. So, we’re constantly rebuilding our body and I think this idea that once diet’s done what it can do i.e. prevent deficiencies, there’s not much more it can do. I mean we’re starting to get there so it’s a return to medications and medical interventions which have a time and place and for me in the hospital, we have a capital of Canada obviously, they send out money to various hospitals. Every hospital is required to balance their own budget. So, it’s publicly funded but privately ran. So, they’re all independent unlike England which is publicly operated across the board. So, there’s always a pressure to reduce costs. So, my hospital is the equivalent of $11 a day for three meals. I don’t know what that is in U.S., probably $7.

 

So, it’s the bare basic. So, people are in there. They’re getting the bare basics. There’s no focus on fiber. Like the typical diet has got 10 grams of fiber. So, then they leave and then it’s really left at a community level. And so, I don’t know what the answer is on this side. I don’t know what the answer is on your side because a lot of people just aren’t going to be reaching out to necessarily dietitians to get that therapeutic intervention if they are seeking treatment options with someone like yourself or maybe someone in private practice. I don’t know. I think until that’s really addressed, it’s not going to happen. We’re not going to get the best possible outcomes.

 

David Wiss:

And I’m convinced that the way to get the best possible outcomes is going to be through more hands-on nutrition and more culinary literacy. Giving someone a hand out about fibers, great, but if you want to get someone from 10 grams of fiber per day to 30 grams a day, you probably have to move slowly and do it gradually over time, progressively increase and really get people excited about understanding the why. Like you’re not just doing this so you have better bowel movements. You’re doing this to provide more precursors to your body and this is actually linked to your mental health because if you’re low fiber, you’re pro-inflammatory. Going high fiber is anti-inflammatory and inflammatory conditions affect all your organs including your brain. So, I try to really give people the mechanisms, help them to understand the why and then I make it clear that you’re probably not going to be able to pull it off if you go to restaurants and just eat commercial food, that the only way to really do it is to get really comfortable in the kitchen. So, the work we’ve done in treatment centers telling people what to eat or providing PowerPoints or handouts is all great. But the best outcomes come when we actually do cooking classes and teaching them how to make—

 

Doug Cook:

Yeah, skill building.

 

David Wiss:

Yeah, skill building. How to make beans and whole grains and eat a cooked a vegetable and a raw vegetable at the meals. Those are the key things that I think are missing and will remerge as important moving forward. And right now being in quarantine, a lot of people are kind of waking up to like actually no, cooking is important and I’ve had a lot of calls and messages of like you told me about cooking and I listened and now I’m cooking all my meals and I feel great. A couple other people are like falling apart because they’re just not comfortable in the kitchen.

 

Doug Cook:

Yeah. No, there is a bit of unintended consequence, people are cooking more which can be good for some, like you said, who know how to do it. So, I don’t want to take up a ton of your time. You’ve been very generous as is. But I’m wondering if you could talk more of specifically about your services, your framework. I mean you’ve alluded to it but I’m just wondering if you can—I know there’s four of you. Maybe you can just summarize it and if for those that it’s not apparent, how might these approaches differ from traditional dietetics? And do you offer virtual counseling for clients?

 

David Wiss:

Absolutely. And being in the current situation we’re in, I’ve been doing lots of Zoom and FaceTime appointments and they’re going really well. I’ve always kind of had a preference for face-to-face and like the unintended consequences of what we’re going through now has led to being able to connect with people from further places and to be effective in the individual counseling domain. The work that I do broadly at the research level I often refer to it as the biopsychosocial model of health. So, it’s really looking at biology, neuroscience, microbiome and then psychosocial factors whether they be—my interest is in adversity. So, since because it’s like with substance use disorder, I’m interested in early life adversity. So, when I work with people that are in recovery, they often see a trauma therapist or getting some form of other treatment. And so, there’s a team approach which is really awesome and I love working with people. I’m in West LA.

 

We do, to answer your question, one-on-one counseling in the office and we bring our services on-site to many different addiction and eating disorder treatment centers for both adults and adolescents. So, we come on-site and bridge the gap. So, people that have addiction treatment centers where there’s disordered eating, once they bring on a dietician from nutrition to recovery, they’re able to get treatment. So, it’ll often include running a group, doing a couple of one-on-ones for at-risk clients or clients that have disordered eating and we’ll often get involved in the food service operation or work with the culinary staff to make sure that our messaging matches the food that they’re serving which traditionally is one of the hard parts. Integrating with the food service operation is not without its challenges. And now we are running groups virtually. So, with everything kind of being on lock, running groups over these platforms has not been without challenges but we’re learning that anything could be done and I’m available for individual counseling with people all over the world and would love to connect with other dieticians that are working in mental and behavioral health.

 

My website NutritionInRecovery.com has a newsletter. Opt-in, it pops in at around 20 seconds where I send out the papers and publications that I’ve been working on. I have several peer-reviewed journal articles coming in the next few months that are currently in prep or in review that I’m really excited about mostly focusing on the link between early life adversity and mental and physical health outcomes over the life course. So, it’s really exciting to be a clinician and to be a researcher and to make contributions in areas where it’s much needed to help people think about nutrition in a new way, to get outside of those prescribed lanes that we talked about, to think outside of the box and to really promote the public’s perception of the dietician and what we are capable of and what we can do to help people throughout the recovery process.

 

Doug Cook:

That’s amazing. I think you’re a pretty niche. I don’t think there’s a lot of people like you. I could be wrong. I’m not sure what your networks are like with the Academy of Nutrition and Dietetics. I’m not sure what the numbers are like. For sure, there’s nothing like that here. So, I’m just excited to see where this goes in the future because yeah, it for sure needs some improvement. So, I wanted to thank you very much for taking the time. On your website, you’ve got other connections I guess through there. Do any social media?

 

David Wiss:

Yeah. Instagram, I have a post every single day. I have a book that I wrote and I’m putting out little excerpts that are super fun basically covering all the stuff we talked about today, nutrition, there’s a recovery stuff, little spirituality in there, a lot of science. My Instagram is @DavidAWiss and I love connecting in the cyber space.

 

Doug Cook:

So, I think a really good thing for people to be directed to especially the professionals, dieticians and other health professionals is that YouTube video I saw of you doing a presentation. I’m not sure if it was to a class or something. I found it on YouTube but is that linked on your website? I believe it is.

 

David Wiss:

Yes. I actually, given the quarantine situation, recorded a brand new presentation two days ago. It’s called “More than Meets the Eye: Linking Nutrition to Behavioral Health.” So, it’s an hour long recorded webinar. I think I blow through 150 slides. I’ve gotten really good feedback so far. It’s the first link on my website. I would definitely recommend spending the hour and sometimes you got to pause it and write the references down and track them down because it’s pretty dense. But it covers a lot of ground.

 

Doug Cook:

Yeah. And that’s what I like about it is because either you’re looking for these things individually, like you’re going to the literature trying to find these little pieces on your own and this is such a comprehensive presentation that it’s kind of like a one-stop shop for everything we’ve talked about. So, I guess that’s it for me. I again wanted to thank you for your time. I know people are going to really like this. It’ll probably be one of the more popular downloads and just say good luck and I wish you well, good mental health during this time of self isolation. Again, thank you very much.

 

David Wiss:

Yeah. Thank you so much. I had a blast today.

 

Doug Cook:

Good.

 

David Wiss:

Ride on.

 

Doug Cook:

Hit subscribe and get ready to expand your nutritional world, your perspective and gain confidence in a way that you didn’t know you could. And be sure to check out my website DougCookRD.com.

 

 

RECORDING ENDS

 

Doug Cook RDN is a Toronto based integrative and functional nutritionist and dietitian with a focus on digestive, gut, mental health.  Follow me on FacebookInstagram and Twitter.

 

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