A Dietitian’s Experience Working in a Psychiatric Children’s Hospital

Kim Rodriguez, MS, RD, LD

The number of psychiatric children’s hospitals in the US is growing. (www.ushospital.info). I am the clinical dietitian for a psychiatric children’s hospital in Georgia. The hospital treats 80 children and is always full with a waiting list for admission. Approximately 86% of admissions are males, 92 % are African American, and 65% are readmissions. Medicare/Medicaid pays for 100% of admissions.

Diagnosis and Treatment

The hospital provides psychiatric and mental health treatment for children and adolescents between ages 9 and 17 for mood, behavior, and anxiety disorders. Some of the children have committed crimes and are too young to be jailed. Most are diagnosed with “conduct disorder,” their parents unable to manage them.

Other children have disorders manifested from family neglect and abuse. At times, the hospital seeks placement in a group or foster home following therapy. Other diagnoses might include anxiety, ADHD, mental retardation, chronic fatigue, substance abuse, and self-mutilation. Medical diagnoses include diabetes, hypertension, and hyperlipidemia (high cholesterol and/or triglycerides). Most children present with multiple diagnoses.

My job responsibility at this facility is to complete an initial assessment on each patient, addressing special diet orders written by the physician. If available, I evaluate blood levels for vitamin deficiency. I am expected to recommend low-fat diet protocols for hyperlipidemia and monitor weight trends during the hospitalization. I think that the true reason that a dietitian is employed at most facilities is to meet state guidelines for reimbursement, rather than actually implementing nutritional therapy.

If a diet instruction is performed, it must be ordered by the physician. One diet instruction has been requested in my 3 years working at this facility, despite the fact that most of the children eat horribly and many are morbidly obese. The instruction requested was for a low-fat, low-cholesterol diet to “lower cholesterol.” The patient was 13 years old and taking a statin drug.

Most physicians think that diet changes are not important, especially if the patient returns to the home environment where the family is not eating or unable to afford proper foods. The hospitals treatment plan is based, and relies, upon pharmaceutical intervention. Changing dietary habits are not and never were a part of the treatment plan.

Based on an actual patient, a diagnosis and treatment plan for a 16-year-old African American male might look like this:

Diagnosis

Bipolar

ADHD

Mild Mental Retardation (low IQ)

Oppositional/Defiant Behavior

Depression – 2 past suicide attempts

Hypertension

Hyperlipidemia

Morbid Obesity – Ht: 64 inches, Wt: 242# BMI:41

Treatment

Lipitor – high cholesterol

Clonidine – blood pressure, ADHD

Lithium – bipolar, depression

Seroquel – bipolar

Metformin – to control the increased appetite caused by Seroquel

Social Services – (social worker)

A diet instruction was not requested. The diet history is poor, consisting of mostly refined foods and sugars. The patient does not drink milk and gets little sunshine. No blood nutritional levels were drawn. No vitamin/mineral therapy is in place.

A Holistic Approach

The patient discussed above is taking Seroquel, a frequently prescribed psychotropic medication. A side effect of this medication is increased appetite and weight gain. The patient was later prescribed metformin to suppress the increased appetite caused by the Seroquel. This medication, usually used to control blood glucose in diabetics, is often prescribed to control appetite in adolescents.^1,2

Metformin is the diabetes drug that I often think of when I think of nutrient depletion. It is thought to decrease the absorption of vitamin B12 by lowering intrinsic factor, or possibly through other mechanisms.^3,4 Reduced serum levels occur in up to 30% of individuals who chronically take metformin. Those with a higher risk of developing the deficiency include this group, whose diet is poor and vitamin B12 intake is most likely inadequate.² IF B12 levels are only slightly lower than normal for a very short period of time, a range of symptoms such as poor memory, fatigue, and depression may be experienced.⁵

A holistic approach would treat the “source” of the disorder, which might include nutritional deficiency. Evaluate B12 blood levels, especially since the child presents with two of the symptoms caused by B12 deficiency. If B12 is low, analyze B12 intake and ability to absorb B12, and suggest that vitamin supplementation would be appropriate if he is unable to meet his increased B12 requirements by food.

Vitamin D levels should also be evaluated, given the fact that this patient does not drink milk and spends most of his days indoors, along with a diagnosis that many studies link to low vitamin D levels.^6,7 In my 3 years working at this hospital, I have never seen a vitamin D or B12 level tested or nutritional supplementation initiated.

A healthful diet program of whole, unrefined foods that work within the family budget should be initiated. The family should be involved in this new nutritional plan.

This approach should not devalue the benefit accomplished by pharmaceutical intervention, which is often necessary. Pharmaceutical therapy to suppress symptoms in combination with healing modalities such as nutritional therapy would be the ideal approach.

The Reality

The prospect of treating psychiatric conditions nutritionally with or without pharmaceutical intervention is promising and researched, but rarely implemented. I think that nutritional therapy is not part of the treatment plan; nor is it sought, because the physician conducts the treatment plan and he is not aware of and/or does not understand this mechanism.

Unless a physician has studied outside what the pharmaceutical industry presents, she only understands how to treat a disease process pharmaceutically. A physician’s education and continuing education (classes, seminars, workshops, books, articles, studies) are conducted and presented via a pharmaceutical or investment partner who is involved and financially motivated within the industry.

Other physicians think that a therapy must be firmly grounded in fact before utilized, something only afforded by the pharmaceutical industry because studies are expensive to conduct.

My biggest frustration is watching a physician’s reluctance to give up “control” of the patient, never asking another practitioner’s advice about a treatment that he does not understand, even if the treatment has no ill side effects.

Good News

I observe more pharmacists, nutritionists, and researchers conducting evidence-based studies on the dangers/side effects of pharmaceutical therapy. Natural Medicines Database (www.naturaldatabasetherapeuticresearch.com) is a good reference, providing a list of medications that cause nutritional depletion, with corresponding studies. It discusses the medications’ side effects, as well as other herbal or homeopathic remedies that may be used alternatively. It lists evidence-based studies linked to the use of herbal and homeopathic remedies and encourages researchers to study and submit material.

I find it encouraging that this is a reference suggested by the Dietitians in Functional and Integrative Medicine practice group of the Academy of Nutrition and Dietetics (formerly American Dietetic Association).

Food

On my first day at this hospital, the administrator requested that I change the menu plan. After seeing the menu, I assumed that the request was because the menu contained many refined foods and sugars. I later found that it was because the patients were complaining about the food.

This is what the menu plan looks like. It follows the guidelines of the Academy of Nutrition and Dietetics.

Breakfast:

Eggs

Sausage/Bacon

Toast/Biscuit/Muffin/Sweet Roll/Pop-Tart/Pancakes

Cold Cereal /Oatmeal

Low-Fat or Skim Milk

Fruit Juice

Lunch/Dinner:

Chicken Nuggets

Pizza

Hot Dogs/Hamburger

Fried/Baked Chicken

Tacos

Salad or Vegetable

French Fries/Potatoes

Roll/Bread

Cake/Cookies/Low-Fat Ice Cream/Sherbet

Canned/Fresh Fruit

Low-Fat or Skim Milk

Fruit Punch/Lemon-Lime Soda

Snacks:

Prepackaged Crackers, Cookies, or Chips

Fruit Juice/Fruit Punch/Lemon-Lime Soda/Low-Fat or Skim Milk

* Products are frozen, prepackaged, or canned. Salad or fruit may be fresh.

I had big plans for changing this menu, hoping to meld WAPF principles (a whole-foods diet as outlined by the Weston A. Price Foundation) into the guidelines of the Academy of Nutrition and Dietetics and teach the patients about dietary changes with classes.

The administrator asked me to first interview the patients to find out what they did not like about the food (the real reason he consulted me) These are some of the answers:

Ranch dressing with everything – the low-fat type because it is sweeter.

Froot Loops and Cocoa Puff cereals

Chocolate Milk

Chicken Wings with BBQ sauce dip

Ketchup at every meal

Coke or Pepsi

Sugar Substitute in the pink package

Icing on the cake

Coffee

Red Bull

When asked what they thought that they should eat to be healthier, the answers were:

Cereal

Oatmeal

Ensure

Energy Bars

Gatorade/Sports Drinks

Low-Fat and Nonfat foods

All of the children obtained their nutrition education from television commercials.

I approached the administrator with a proposal to provide more healthful meals and snacks, consisting of less sugar and refined foods, and start weekly nutrition classes. I let him know that the cost of the meals would increase, as well as the cost for me to conduct the classes. I also informed him that this is not what the patients had “requested.” My proposal was immediately vetoed, followed by an explanation that the hospital must contain costs.

A few months later I was asked to conduct nutrition classes in order to meet state funding requirements. I found the instruction difficult, as I was telling them to avoid the very foods that were served.

Conclusion

Treatment success looks only at results. Outward appearance is not the inward reality. These children are not healing disease at this hospital. The treatment is merely combating/masking symptoms with pharmaceutical intervention – “Illness maintenance based on system suppression.” To heal these children, physicians must rely on a practitioner with training outside the pharmaceutical model in the treatment plan.

We must end the monopoly that the pharmaceutical and refined-food industries hold on nutrition and health care. Until we do this, we will only become sicker while the current health-care industry of pharmaceutical therapy and invasive procedures explodes.

Notes

1. Paoliso G. Effect of metformin on food intake in obese subjects. Eur J Clin Invest. June 1998;28(6):441–446.

2. Davidson MB, Peters AL. An overview of metformin in the treatment of type II diabetes mellitus . Am J Med. Jan 1997;102(1):101–110.

3. Callagan TS. Megaloblastic anemia due to Vitamin B12 malabsorption associated with long term metformin treatment. Br Med J. 1980;280:1214–1216.

4.Gilliagan MA. Metformin and B12 deficiency. Arch Int Med. 2002;162:484–485.

5. Dietary supplement fact sheet – B12. Office of Dietary Supplements, National Institutes of Health. 28 September 2011.

6. Walling E. Vitamin D may prevent and reduce symptoms of depression [online article]. Natural News.com. February 10, 2011. http://www.naturalnews.com/031273_vitamin_D_depression.html.http://www.naturalnews.com/031273_vitamin D_depression.html

7. Mental health and learning disorders [Web page]. Vitamin D Council. http://www.vitamindcouncil.org/health-conditions/mental-health-and-learning-disorders.

Kim Rodriguez is a consultant dietitian who originally obtained her training from the world of allopathic medicine and the American Dietetic Association. After becoming ill with diabetes, obesity, severe chronic fatigue syndrome and relying pharmaceuticals, she looked for methods of healing outside of what mainstream medicine offered. For 10 years, she studied nutrition among naturopaths, chiropractors, acupuncturists, and other nutritionists, resolving her health problems with dietary changes that included saturated fats and whole-food supplements. She has since helped others do the same via a private nutrition practice. Kim hopes to see our health care system (Medicare/Medicaid) reimburse this type of nutrition therapy so that nursing homes, hospitals, and rehabilitation facilities can use it, finally affording patients a real healing process.