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An application of integrative medicine

September 1, 2009
by Carolyn Coker Ross, MD, MPH
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Nutritional and other therapies can assist with co-occurring substance use and eating disorders

Eating disorders (EDs) such as bulimia nervosa and anorexia nervosa involve many features similar to those present in substance use disorders (SUDs). Both involve a preoccupation with a substance and with the behaviors accompanying the addiction. Both involve some impulse control issues and the inability to stop doing something that is harmful or addictive. In individuals with bulimia, impulse control issues might include sexual promiscuity, bingeing and the use of drugs and alcohol. Individuals with anorexia exert excessive control to the point of self-starvation and are unable to stop their impulse to restrict.

A review of studies on the co-occurrence of eating disorders and substance use disorders showed that 23% of individuals with bulimia reported alcohol abuse, with 26% reporting drug abuse. For anorexics, the prevalence of drug use was 19%. Of those with a SUD, 8 to 20% have a current or past history of bulimia and 2 to 10% have a current or past history of anorexia.1

Between 50 and 70% of individuals with bulimia have a SUD. Binge eating is associated with heavier use of substances as well as higher rates of depression and low self-esteem.2 Those with bulimia and alcohol dependence have higher rates of suicide attempts and anxiety disorders and are more likely to use other drugs and have borderline or histrionic personality disorders.3 SUDs appear to be higher in ED patients than in healthy controls.4

Integrative medicine is a healing-oriented discipline that takes into account the whole person-body, mind and spirit-including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of both conventional and alternative therapies. While integrative therapies have not been considered part of a traditional approach to the treatment of either eating disorders or substance use disorders, they can be beneficial in the treatment of these co-occurring disorders. The remainder of this article will discuss some of the most promising therapies.

Nutritional strategies

Nutritional therapies are essential in treating EDs but also have a place in SUD treatment. Individuals with SUDs often eat poorly, which limits absorption of vitamins and minerals needed to maintain essential body functions. Approximately 80% of ED clients and two-thirds of those with SUDs will experience depression in their lifetime, and individuals with depression also have nutritional deficits. Several categories of nutritional therapies are potentially useful.

Omega-3 fatty acids are essential fatty acids because the body cannot manufacture them. EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are omega-3 fatty acids found in cold-water fatty fish (such as salmon, tuna, mackerel and sardines) and fish oil. Vegetarian sources of fatty acids come from algae or from walnuts and flaxseeds (which must be fresh ground) and contain a precursor to DHA and EPA called alpha-linolenic acid (ALA). Populations with the highest seafood intake have the lowest levels of illnesses such as major depression and bipolar disorder. Omega-3 fatty acids have been shown to decrease the risk of and/or treat depression and schizophrenia and to decrease aggression and hostility in borderline personality disorder.5

Typical dosages range from 2 to 5 grams per day. One note of caution: There is a theoretical risk of bleeding in individuals who are taking blood thinners, although there have been no reported cases.

B-vitamins, including B-12, folic acid and B-6 (pyridoxine), are required for the synthesis of neurotransmitters in the brain. Individuals with depression and alcoholics have low levels of B-12 and folic acid as well as other B-vitamins. Supplementation with folate may increase the effectiveness of antidepressants6 and low levels of folate are implicated in poor response to antidepressant therapy.7

A B-complex vitamin taken once a day can be used to obtain adequate amounts of all the B-vitamins.

Vitamin D is important because alcoholics and some individuals with EDs are at higher risk for bone loss and osteoporosis. Vitamin D is an important nutrient for bone health. Sources for vitamin D besides conversion in the skin by sunlight include foods such as cereals or milk products. Another source is cod liver oil. Egg yolks, beef liver and cheese contain small amounts as well. There is some newer preliminary evidence supporting the use of Vitamin D-3 (cholecalciferol) over Vitamin D-2 (ergocalciferol).

Alcohol consumption interferes with the production of vitamin D. Certain medications may lower vitamin D levels as well. These include Dilantin (used for seizures), steroid medications such as prednisone used to reduce inflammation or treat asthma, and Questran (cholestyramine), a cholesterol-lowering medication.

A dosage of 1,000 IU daily is appropriate for Vitamin D-3.

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