Kelty Mental Health Pinwheel Education Series: Nutrition and Mental Health

In this Nutrition and Mental Health recording from the Kelty Mental Health Pinwheel Education Series, Laurie Chow, Helen Young and Brent Field offer three perspectives on nutrition and mental health for children and youth.  Whilst this discussion is targeted specifically to helping manage mental health issues, many of the practical nutritional suggestions offered have general applications useful to all families. Laurie Chow is a registered dietician working at the provincial Mental Health Metabolic Program at BC Children’s Hospital.  She has helped write the Healthy Living Toolkit, a toolkit that helps health care professionals support healthy living in children and youth with mental health challenges. Laurie talks about the link between mental health and nutrition, identifying some of the common issues around mental health and nutrition.

For more detailed information, Laurie recommends three resources available on the Kelty Mental Health website:

• Healthy Living Toolkits for families and for professionals have general nutritional information for children and youth with mental health challenges
• The Family Guide, developed by a collaborative group of mental health support agencies, includes helpful tips from parents dealing with mental health issues in the everyday life of their families.
• The Patient and Family Guide to Second-Generation Anti-Psychotics discusses more specific nutrition and physical activity for some of the side effects of these medications.

Laurie focuses on the broad connections between nutrition and mental health. For more specific nutritional information connected to specific treatments, she recommends the Healthy Living Toolkit for professionals, which has a summary of current findings and recommendations.

1. Many mental health drug treatments are linked with increased appetite and weight gain.  This can be connected either to mood or to commonly prescribed medications.
2. Micro-nutrient deficiencies or excesses have been identified with certain eating habits or alternative therapies used to attempt to modify mental health challenges (e.g. iron deficiency in the management of autism).
3. Poverty and isolation are commonly found associated with mental health challenges, including food security issues and challenges in accessing and preparing good quality nutrition.
4. Core morbidities (e.g. cardio-vascular morbidity) are associated with some mental health diagnoses; diabetes is associated with some mental health issues, particularly with schizophrenia.

In practice, Laurie, like many other mental health professionals, has found that small, incremental, measurable changes (SMART goals) are most effective in building long-term change in family situations where there has been considerable resistance to change or challenges in creating sustained change in nutritional habits.  An example would be increasing the amount of fibre in the toast being eaten by someone on a prescribed anti-psychotic from 2 grams per serving to 4 grams per serving.  This type of goal feels achievable and success in meeting it helps to build confidence to try other changes.  The aim is to make incremental, sustainable changes slowly over time.

Commonly prescribed second-generation anti-psychotics can cause an increase in appetite, leading to weight gain around the belly, and elevated cholesterol, insulin or prolactin.  Increasing fibre through greens, or drinking fluids before meals can make the body feel more full.

Another major class of medications is stimulants, which can cause the opposite side effect; the lack of appetite and subsequent weight loss.  It can help to include higher-energy food options, scheduling small, frequent meals and snacks throughout the day, and making sure kids aren’t drinking before or during a meal, so that their stomachs won’t get filled up with fluid.  Some kids find it helpful to have a bag of trail mix with them that they can munch on throughout the day.

Children and youth with mental health issues are more likely than typical children to have very picky eating habits.  The first suggestion in this case is to maintain the ‘division of responsibility’, where parents provide regularly scheduled meals and snacks and the child decides whether or not to eat what is provided.  The parent should not be expected to be a short-order cook providing for individual demands throughout the day, or ‘a la carte’ choices at scheduled meal times.  If parents aim to have at least one food item per meal that the child is likely to accept, then food choices are likely to expand naturally over time by avoiding having the table become an emotional battleground for control.

Using food as a reward for behaviour:  Laurie finds this issue happening frequently with her clients, as well as giving children food treats when they are not feeling low in spirits.  The danger with this is in linking food with emotions.  Food should be for nourishment, not an emotional crutch.   Linking food rewards to behaviour or emotional states can lead to problem eating patterns in adulthood, and can exacerbate pre-existing or underlying health problems.

Helen Young has worked as a community dietician with Vancouver Coastal Health for the past 20 years, mostly with children, youth and their families.  In her current role, she works with school staff, parents and community members to promote healthy living in all children and youth.  She is also a dietician with the North Shore Eating Disorders Program, seeing young people 11-18 years old who are struggling with disordered eating or eating disorders. Helen participates on the North Shore Education Committee for the Prevention of Disordered Eating, which includes representatives from public health, mental health, school districts and the Family Services of the North Shore.

Helen focuses on reviewing messages and strategies that can help to promote positive mental health in children and youth.  While Laurie covered a number of issues in dealing with individuals, Helen looks here at a more wide-angle lens view of eating disorders and mental health in children and youth.  In her work, Helen deals with individuals, their families, school environments, school staff, and community, including food suppliers, community centres and other providers. She would like us all to think about how we can play a role in promoting healthy eating at home, at school and in the community.

The comprehensive school health model includes four pillars:

1. Relationships and environment (i.e. social and physical environment)
2. Teaching and learning
3. Community partnerships
4. Policy

If we have coordinated action in all four areas simultaneously, we can be more effective in creating change.

Three common nutrition issues that youth, parents and teachers frequently raise with Helen in her practice are:

1. Body image concerns
2. Skipping breakfast
3. Lunch: teens wanting new ideas for tasty, healthy lunches, or not having enough time to fit in a meal at lunchtime.

Body image concerns often drive youth’s eating or non-eating patterns and their attitudes.  While body image is a normal concern in adolescence, it is exacerbated by our society’s focus on the ‘thin’ ideal, and for males, the ‘muscular’ ideal.  The message youth receive is that you can look like the model in this magazine if you just try hard enough.  They come to believe that if you diet or exercise enough, you can change your body type and composition.  In her discussions with youth, she uses the analogy of someone well known who is tall:  would you say to them, “You should lose some height, or some inches”?  If you have big feet, maybe you should shrink your feet?  It is helpful to grasp that your adult height and body type are not changeable, and there is a genetic limit to how much you can change your body size.  Every body benefits from being active (about an hour a day of enjoyable, moderate activity) and eating well.

Pre-teens (10-12) worry a lot about their changing bodies and often don’t realize that part of normal growth involves the body increasing in weight and size before it moves into a height growth spurt.  Eating well (quality and quantity) at this age is important to help our bodies with this major work of physical growth.  Our body give us signals, in terms of appetite changes, as it moves in and out of growth and stabilization phases, and we need to pay attention to these signals to help us regulate our quantities, whilst maintaining a healthy balance of food intake.

Schools are looking at self-management training within curriculum, including being responsive to our physical and emotional body signals.  Ask yourself key questions:  “Is this feeling I am experiencing one of hunger, thirst, tiredness, etc.”  School-aged children and youth frequently forget to keep themselves properly hydrated, leading to feelings of tiredness, lack of concentration and irritability.  Food restriction (dieting) also leads to mood swings and irritability, affecting social interactions, concentration and mood.  Maintaining a healthy balance, pattern and quantity of food helps prevent symptoms that can cause social and educational challenges.  Eating every three hours in the daytime helps regulate our body chemistry, moods and mental functioning.

Changing language and attitudes around food:  as a society, we tend to label foods as “good” and “bad” foods.  It can help to change this value-driven language in dealing with children and youth.  A helpful starting point can be to frame food choices as being about managing energy levels and health, as part of a plan to maximize our physical and mental functioning (self-care rather than morality).  Healthy eating is defined by flexibility, moderation and balance, not rigidity.  Mindful eating, savouring tastes, being aware of taste and texture, eating slowly, chewing thoroughly, enjoying and appreciating the smells, taste and texture of the food you are eating, and thinking about how that piece of food got to you, help to create a healthy context for nutrition.

Helen finds it important to ask the question, “Why do you choose the foods you eat?”  Often the response of children and youth will be that it is what is readily available in the school food fair, or easily accessible.  Youth often eat for convenience.  They will eat what is in their school, what is in their bags, what is in their home.  BC now has guidelines for food sales in BC schools; the 2010 guidelines are the most recent, but new, revised guidelines will be coming out soon. Helen feels that having the guidelines is an important piece for determining the quality of the food choices being made available to children and youth within their school environment.  The guidelines are designed to open up a range of healthier choices for students, with increased culturally diverse options.

Missing meals can be related to a variety of issues:  food security, parents needing to drop children off at school early so that the parents can get to work, food preparation skills, etc.  Helen starts by thinking outside the traditional breakfast menus.  She encourages people to add protein and fibre to the meal (helps concentration and learning).  She recommends planning a breakfast that has at least three food groups represented (e.g. toast, peanut butter, fruit and milk or milk alternative).  Try sweet potato, rice and fish, etc.  Widen the variety of foods; concentrate on food groups.  Vancouver Coastal Health (VCH), at http://www.vch.ca/about_us/news/packed-lunches-that-make-the-grade has a number of cost-effective, healthy packed lunch menus and suggestions.  Helen suggests parents go through the list with their kids, have them mark the ones that appeal to them, and use that as the basis for building a shopping list.  Another useful VCH handout available online is Fueling Your Mind and Body http://vch.eduhealth.ca/PDFs/BB/BB.200.F952.pdf Developed for youth, It goes through both the “what” and the “how” of healthy eating.

Helen also stresses that eating in community has great benefits, particularly eating as a family on a regular basis.  There is a lot of research showing the benefits of families eating together, particularly in increased self-esteem and sense of belonging, eating healthier, and in youth being less likely to smoke, use substances, or have disordered eating.  It also helps parents to eat healthy foods and spend less money, and to be a role model for their kids.  If family schedules make this challenging, aim for weekend dinners or evening snacks together.

Helen’s final recommendations for parents, caregivers and those working with children and youth: modeling healthy eating and healthy attitudes around food, providing an environment that offers a range of healthy eating options for our kids, focusing on health and attitudes rather than weight, and providing a supportive environment where there is lots of talking and lots of listening.

Brent Field is a former Youth-in-Residence at the Kelty Mental Health Centre who has lived with schizophrenia since 2007.  For the past two years he has been learning and applying nutrition strategies to help him manage symptoms, improve his mood and energy, achieve and maintain a healthy body weight, and run his first ultra-marathon.  Brent promotes a guilt-free approach to nutrition that is simple and sustainable.

After his second psychotic episode, Brent increased his anti-psychotic medications and began to experience side effects including weight gain, low energy, dramatic change in prolactin levels, etc.  He realized he needed to take control of his general health management and, in the spring of 2012, he decided to do a wellness challenge.  He decided to do everything all at once, adding in drinking green tea, getting to sleep on time, getting exercise 5 times a week, etc. While eliminating coffee, tea and fast food.  He lasted 5 days of his month challenge before getting completely overwhelmed!

Brent decided instead to focus on just one thing at a time, choosing exercise.  As soon as he began to develop a regular pattern of exercise, he found himself instinctively wanting to eat healthier.  With the support of his girlfriend, who was highly motivated to living a healthy lifestyle, they started to read books on nutrition and exercise and they decided to move gradually towards a more vegan diet, by increasing micro-nutrients.  Ultimately, while appreciating the benefits of increasing micro-nutrients in their eating, they decided that a vegan diet was too restrictive to appeal to them long term.  They had heard of an approach, the “80%-20%” approach, which appealed to them and which they have adopted, a “guilt-free” eating approach which involves eating 80% healthy, plant-rich foods and 20% of eating whatever you want.  They found this allowed them to significantly improve the nutritional quality of their eating, whilst enabling them to more easily maintain social relationships within their community.  They have found it attainable and manageable long term.

Increased energy from his improved nutrition, and a switch in medication that enabled him to better manage his prolactin levels, has enabled Brian to maintain his fitness goals and keep his mental health in good balance.  His nutritional aims have been to:

1. Increase the micro-nutrients in his diet
2. Increase the quality of the macro-nutrients in his diet
3. Apply his learning about gut health and the role of probiotics, and their relationship to brain functioning

Brian has found it helpful to use smoothies as a base for adding micro- and high-quality macro-nutrients to the diet.  He has significantly increased his consumption of organic food.  He has also decreased his consumption of dairy and gluten, which has happened naturally by maintaining the 80%-20% balance.  The biggest thing he has found has been that moving step by step, incrementally, to add healthier foods has regulated his eating habits naturally and effectively, rather than by attempting to eliminate foods or restrict consumption.  The combination of increased food quality, sleep and exercise has contributed significantly to the improvement and regulation of his mental health over the last couple of years.  Feeling the benefit of increased wellbeing and energy has provided intrinsic motivation to continue with the eating patterns and lifestyle he has evolved.

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