16 Dietitians and their role in mental healthcare
Learning Objectives
- Describe the role of dietitians in supporting mental and physical health through multidisciplinary care.
- Identify key dietary assessments and interventions for managing mental health conditions.
- Explain how evidence-based programs like CALM and SMILES benefit mental health.
- Evaluate the impact of social determinants on dietary interventions in mental health care.
Introduction
Dietitians play a crucial role in mental health care, addressing the complex relationship between nutrition, lifestyle factors, and well-being. Good food choices, food insecurity, and excessive appetite are among the many factors impacting physical and mental health, where dietitians provide essential support and guidance for individuals experiencing mental illness (Teasdale et al., 2022). The inequality in physical health outcomes contributes to a life expectancy 10–15 years shorter for those living with mental illness in Australia (Walker, McGee & Druss, 2015). With diet playing a significant role in these disparities, the need for dietitian support is critical (Burrows, 2022). Despite this growing recognition, there is limited data on the number of dietitians currently working in mental health care in Australia (Teasdale et al., 2022).
The Role of Dieticians in Australian mental health care
The Dietitians Association of Australia can provide credentialing to Dietitians, allowing them the working title of Accredited Practising Dietitians (APDs) (Teasdale et al., 2018), within this role they can use their knowledge of food and nutrition as well as mental health to work as part of the team to support a person’s well being.
Within Australia conditions such as diabetes, respiratory diseases, obesity and cardiovascular diseases are commonly seen as comorbidities for those living with a mental illness, with dietary interventions being recommended as part of best practice management (Burrows, 2022). When factors such as education and socioeconomic status are considered, the role for dietitian input can be seen as significant (Burrows, 2022).
In Australian healthcare, the 15–20-year life gap discrepancy for those with a mental illness can be linked not only to the above diseases but also to unhealthy lifestyle practices that are considered unhealthy, and the impact of metabolic effects of psychotropic medications (Teasdale et al., 2018). Psychotropic medications,whilst essential for managing mental health conditions,often lead to significant side effects that worsen physical health risk. These side effects can include changes such as increased appetite and abnormal endocrine responses, evidenced by changes in lipid and glucose levels compared to a person living well (Teasdale et al., 2018).
For Dietitians this means they can play a vital role through dietary assessments and interventions to support a person’s well-being and improved health outcomes .Dietary assessment examples include:
- Body girth measurements
- Eating behaviours – dietary intake
- Biochemistry interpretation such as glucose levels and lipid levels
- Nutrient/drug interactions and the impact
Dietary Interventions
- Education regarding food choices
- Strategies for behaviour change
- Goal setting
- Life skill development (cooking nutritional food). (All of this would be considering the social determinants of health) (Teasdale et al., 2018).
Examples of what mental health disorders dietitians can be involved in:
(Please note that this is not an exhaustive list).
- Depressive disorders
- Anxiety disorders
- Bipolar disorders
- Personality disorders
- Substance use disorders
- Stress disorders
- Obsessive compulsive disorders
- Neuro-cognitive disorders (Teasdale et al., 2022).
When considering the connection between mind and body and the bi-directional relationship it is important to watch what is being recommended. The Royal Australian & New Zealand College of Psychiatrists’ guidelines for the management of mood disorders is one such example. They are endorsing the use of lifestyle therapies (one example being nutritional guidance) as needing to be done with, or prior to, the prescribing of any other forms of treatment (O’Neil et al., 2024).
Both above-mentioned clinical trials have been conducted in Australia and had primary input and leadership from Dietitians.
SMILES and CALM studies
Curbing anxiety and Depression using Lifestyle Medicine (CALM) is a lifestyle program created and delivered by Dietitians and Exercise Physiologists who are endorsed by their respective governing bodies (O’Neil et al., 2024). Whilst Nutrition and physical activity were recognised as the primary focuses, alcohol use, smoking or substance use, and sleep hygiene were also included in the program. The trial showed evidence of success in reduction of clinical depression through remote delivery (online and telephone) of lifestyle therapy, having the same or similar efficacy as psychotherapy over an 8-week period (O’Neil, et al., 2024). not devalue tools such as CBT, but demonstrates how multiple therapies delivered in conjunction with each other can support a person’s well-being. The program actually adapts a CBT model for use within the program that was led by psychologists, again an example of interdisciplinary collaboration.
Supporting the Modification of Lifestyle in Lowered Emotional States (SMILES) was a clinical trial that was run by Dietitians. The program consisted of seven consultations regarding a person’s nutrition, led by a clinical Dietitian (Jacka et al., 2017). This was partially based on a meta-analysis of study data that demonstrated how certain foods, representative of a ‘Mediterranean diet’ had associations with lower risks of depression in adults, this was approximately a 30% reduction is risk (Jacka et al., 2017). The results, whilst not exhaustive due to the limited population captured, do lead to the recommendation of clinical Dietitians being a part of a regular mental health team.
While diet is emerging within the literature as a lifestyle aspect with links to mental health, it follows many other links between lifestyle and mental well-being that have recently been established, e.g. exercise (Sing et al, 2023).
Case Example: Dietitian in Mental Health Care
Background: Sajan is a 30-year-old woman who has been struggling with severe depression and anxiety for four years. Despite ongoing talking therapy and medication, her symptoms have remained challenging to manage, and she reports fatigue, poor concentration, and frequent mood swings. Sarah’s therapist refers her to a dietitian to explore the role of nutrition in supporting her mental health.
Assessment: Upon initial assessment, the dietitian, Jane, conducts a thorough review of Sajan’s dietary habits, medical history, and lifestyle factors. Sarah reports irregular eating patterns, often skipping meals, and eating mostly heavily processed foods due to time constraints and lack of appetite. She also struggles with low energy and motivation, which affects her ability to prepare healthy meals. Sajan’s diet is low in fruits, vegetables, and whole grains, and she often consumes excessive amounts of sugary snacks, energy drinks and caffeine to combat fatigue.
Intervention: Jane identifies several key areas where nutritional interventions could benefit Sajan’s mental health:
Stabilizing Blood Sugar Levels: Sajan’s irregular eating patterns and high sugar intake could be contributing to mood swings and fatigue. Jane educates her on the importance of regular meals that include balanced macronutrients (protein, healthy fats, and complex carbohydrates) to stabilize blood sugar levels throughout the day.
Boosting Omega-3 Fatty Acids: Jane recommends incorporating more omega-3-rich foods like fatty fish (salmon, mackerel) and plant-based sources (chia seeds, walnuts) to support brain health and potentially reduce depressive symptoms. Sajan is advised to aim for at least two servings of omega-3-rich foods per week.
Micronutrient Deficiencies: Jane suggests testing for deficiencies in key nutrients that support mood regulation, including vitamin D, B vitamins (especially folate and B12), and magnesium. Sajan is advised to consider supplements if blood tests reveal deficiencies, alongside increasing food sources like leafy greens, nuts, seeds, and fortified foods.
Reducing Caffeine and Sugar: To reduce the potential negative impact of excessive caffeine and sugar on sleep and mood stability, Jane helps Sajan set a plan to gradually reduce her intake of caffeinated beverages and sugary snacks.
Mindful Eating Practices: Jane encourages Sajan to adopt mindful eating techniques to reduce emotional eating patterns and improve digestion, particularly around high-stress times of the day. This includes eating without distractions, savouring each bite, and paying attention to hunger and fullness cues.
Outcome: Over the course of three months, Sajan reports gradual improvements in her mental health. She experiences more stable energy levels throughout the day, with fewer mood swings. Sajan’s anxiety and depressive symptoms are less intense, and she notices improvements in concentration and sleep quality. Her relationship with food becomes more positive, and she begins preparing meals that are both nourishing and enjoyable. While her mental health treatment continues under the care of her therapist, Sajan finds that the nutritional changes have played a significant role in her overall well-being.
Conclusion: This case study highlights the importance of incorporating a dietitian into a multidisciplinary mental health care team. Nutrition plays a critical role in supporting mental health, and dietary interventions can complement traditional therapies like medication and counselling. By addressing nutritional gaps and improving eating habits, a dietitian can help patients like Sajan achieve better mental health outcomes and improve quality of life.
Case Example: Dietitian’s Role in Mental Health Care for a Man with an eating disorder
Background: John is a 28-year-old man who has been struggling with bulimia nervosa for the past three years. He has a history of binge eating followed by purging behaviours (vomiting and excessive exercise) to control his weight. John presents with low self-esteem, anxiety around food, and difficulty managing stress. He has recently started therapy and is referred to a dietitian to address the nutritional concerns and cognitive beliefs about food associatedwith his eating disorder.
Assessment: Upon meeting with the dietitian, Rachel, John describes a constant preoccupation with food and body image. He frequently skips meals, then binges on large quantities of high-calorie foods, followed by purging to prevent weight gain. His physical health is also impacted: John has a low body mass index (BMI), electrolyte imbalances, and reports feeling fatigued, dizzy, and irritable.
Rachel performs a detailed assessment that includes:
- Nutritional History: John’s restrictive eating patterns, followed by overeating and purging, have led to inadequate calorie intake, nutrient deficiencies, and poor blood sugar control.
- Psychological Considerations: John’s fear of weight gain and feelings of guilt around eating make it difficult for him to establish a healthy relationship with food. His eating behaviours are often linked to emotional stress, anxiety, and feelings of lack of control.
- Physical Health: John’s purging behaviours have caused imbalances in electrolytes (notably low potassium), dehydration, and digestive issues. He is also at risk for long-term damage to his heart and gastrointestinal system.
Intervention: Rachel develops a nutrition-focused, compassionate approach to help John recover and build a healthier relationship with food. Key components of the intervention include:
Re-establishing Regular Eating Patterns: Rachel works with John to create a structured meal plan to stabilise his eating habits. The goal is to ensure regular meals and snacks throughout the day, focusing on balanced meals that include adequate calories, protein, healthy fats, and carbohydrates. The meal plan is designed to be flexible, with options that help reduce the fear and anxiety around eating.
Addressing Nutrient Deficiencies: Given John’s history of restricting and purging, Rachel identifies key nutrient gaps, including protein, vitamins (especially B12 and folate), and electrolytes (potassium, magnesium). She advises John to include foods rich in these nutrients, such as lean proteins, leafy greens, whole grains, and legumes. In some cases, supplements are introduced to address deficiencies and prevent further health complications.
Mindful Eating and Overcoming Fear of Food: Rachel encourages John to practice mindful eating, focusing on being present during meals rather than eating impulsively or out of guilt. Mindful eating involves noticing hunger and fullness cues, eating slowly, and avoiding distractions (such as eating in front of a screen). Rachel also introduces psycho-education and cognitive-behavioural strategies to challenge negative food-related thoughts and beliefs, helping John understand that eating regularly is essential for physical and mental health.
Breaking the Cycle of Bingeing and Purging: One of the most critical aspects of John’s recovery is addressing the binge-purge cycle. Rachel helps him implement strategies to cope with urges to binge, such as identifying emotional triggers, using stress-reduction techniques (e.g., deep breathing or journaling), and avoiding restrictive dieting practices. Gradually, Rachel helps John understand that sustainable weight management comes from balanced, consistent eating, rather than from extreme behaviours.
Education on Health Risks: Rachel educates John on the long-term health risks associated with bulimia, such as cardiac arrhythmia’s, digestive issues, dental erosion, and bone density loss. This information, delivered with empathy and care, empowers John to prioritise his health and begin the process of recovery.
Collaborating with the Treatment Team: Since eating disorders are complex and multifaceted, Rachel collaborates closely with John’s therapist, physician, and psychiatrist to ensure a coordinated approach to treatment. Regular communication between team members ensures that both the psychological and nutritional aspects of John’s recovery are addressed simultaneously.
Outcome:
After six months of treatment, John experiences significant improvements:
- Reduction in Eating Disorder Behaviours: John’s episodes of binge eating and purging decrease dramatically as he gains a better understanding of his relationship with food. He feels more in control of his eating habits and less anxious about food.
- Improved Physical Health: With regular meals, electrolyte imbalances are corrected, and John reports feeling more energised. His lab results improve, and his digestive issues begin to subside.
- Increased Psychological Well-being: John experiences greater self-acceptance and reduced anxiety around eating. While he continues therapy to address underlying emotional issues, his relationship with food becomes more balanced, and his self-esteem improves.Conclusion: This case study illustrates the critical role a dietitian can play in the treatment of eating disorders. A dietitian’s expertise in nutrition therapy, meal planning, and emotional support around food is essential in helping individuals like John recover from restrictive and disordered eating patterns. Through a combination of nourishing the body, addressing nutrient deficiencies, and promoting positive behavioural changes, dietitians help patients regain health, reduce the cycle of disordered eating, and develop a healthier, more sustainable relationship with food.
Summary
Dietitians play an important role when considering collaborative care for people experiencing mental health illnesses. Dietitians in hospital can guide and educate people around dietary changes to manage and address metabolic changes and concerns. Within a community setting this can also be a valuable support. Addressing nutritional needs and diagnosis of nutritional issues or concerns for individuals living with mental illness, groups of people or even communities of people is part of the scope of practice of Dietitians in Australia. As part of a multidisciplinary team this expanding role needs to be understood for the significant role in bridging both mental and physical well-being for people.
References
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