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and addiction – can dietary changes assist with recovery?

Margherita Grotzkyj-Giorgi Margherita Grotzkyj-Giorgi is completing a PhD on the role of nutrition in relation to misuse in socially excluded populations, at the Centre for Health Services Studies at the University of Kent.

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Abstract While many of the most widely used treatment interventions engage with the psychological, social and spiritual dimensions of addiction, some of the biological aspects can at times be neglected. It is increasingly being recognised that there is a close, exacerbating relationship between problematic substance use and poor nutrition.

Key words Nutrition, alcohol and drugs addiction, brain function recovery, biology

In many cases, dietary imbalances relating to amino Drug and alcohol abuse can significantly damage acid, , healthy fats, good the digestive processes of the body, and many addicts and , can lead to a wide variety of experience digestive problems such as constipation, medical problems such as cognitive impairment diarrhoea, indigestion and poor appetite (Holford et (memory), heart disease or diabetes. These are al , 2008).The damage of the delicate inner lining of often accompanied by a host of psychological and intestines caused by chronic alcohol or heroin abuse behavioural issues. For many people struggling with impairs the absorption of amino acids, vitamins and drug dependence, learning about good nutrition minerals (Holford et al , 2008). A healthy gut means is critical in the recovery process and is often a healthy brain too. The gut’s job is to extract instrumental in securing long-term success. from digested food, such as the amino Users of different substances are confronted by acids from proteins to make . different challenges. Alcohol is so calorie-dense Vitamins and minerals are needed to make them (with seven calories per gram of alcohol it is second work properly, so having a healthy gut is key to only to fat, with nine calories per gram) that getting the brain working properly. Addictive drinkers often experience a sense of being sated. In substances, mainly alcohol, caffeine, painkillers fact, these ‘empty’ calories do not support the health and heroin, can damage or even shut down the of the body and over time produce a chronic state digestive processes, preventing the brain from being of malnutrition. Opiate or cocaine users are often so nourished properly. Conversely, a well-nourished distracted by the cycle of getting high, crashing and brain means fewer withdrawal symptoms during the looking for another high, that eating and self-care early stages of detoxification and higher possibility are severely neglected. of achieving long-term recovery.

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In some worst cases (ie. severe addicts or also important implications for mood, as when intestines are severely damaged), short-term deficiency of nutrients like amino acids, folic intravenous nutritional therapy may be required in acid and the other B-complex vitamins also order to bypass a severely damaged gut. Generally have a serious impact. Sugar and caffeine can (ie. when the addiction is not severe), a good generate mood swings, so intake of both should with short-term nutritional supplementation should be reduced during the early stages of recovery recover a poor gut and in turn revitalise the brain. (Holford et al , 2008). Regular intake of good-quality, fresh food should provide enough macronutrients and micronutrients and to help in maintaining a drug-free lifestyle. Alcohol and drug use prevents the body from During the initial phases of recovery, however, properly processing two important amino acids, special emphasis should be placed on educating tyrosine and tryptophan. They are responsible for service users about changing dietary habits and the production of the neurotransmitters adrenalin, moving from a - and convenience food- and . These compounds are based diet to a healthier diet, without falling into essential for emotional stability, mental clarity and a food deprivation. Indeed, caloric intake should general state of well-being (Bandaret & Lieberman, be substantial but calories should be coming from 1989). Decreased levels of these neurotransmitters fresh, good quality food like fruits, vegetables, , negatively affect mood and behaviour. In fact, drug nuts and pulses rather than trans-fat-laden, highly craving and other abstinence symptoms are the processed convenience food like ready meals, fish result of malfunctions of reward centres of the brain and chips, cakes and sweets. The processing of involving the neurotransmitters and the enzymes food and addition of colorants and preservatives that control them. Research indicates that it is depletes food of essential micronutrients and in possible to reduce stress, depression and anxiety, the case of fats, transforms natural, beneficial fatty as increase glucose and neurotransmitters receptor acids into ‘synthetic’ molecules (trans-fats) that sensitivity, and to restore serotonin, dopamine, are not recognised by enzymes and may end up enkephalins, taurine and gamma-aminobutyric stored in fat cells or, worse, they may interfere acid (GABA) with supplementation, with biochemical processes. On the other hand, which will give the client a generally improved fresh food, or food properly prepared and cooked, feeling of well-being (Brown et al , 1990; Bonner retains macro- and micronutrients, fibres and water et al , 2004). that are essential for correct functioning of the is a precursor of tyrosine that is body and mind. then used to produce dopamine and noradrenaline. The education process of choosing healthy and Supplementation with phenylalanine has been nutritious food should be carried out within the shown to elevate mood, increase confidence, context of psychological and social re-education motivation and energy levels, and indirectly (Battaglia, 2008) because learning to eat properly is decrease drug cravings (Ehrenpreis, 1983). part of learning to care for oneself. Good nutrition, Tyrosine supplementation has been indicated to relaxation, and exercise all play an important role increase energy and emotional/mental alertness in successful detoxification from alcohol and drugs (Bandaret et al , 1989). abuse. Learning to make healthy food choices is Tryptophan is integral to the production of important to achieve a healthy lifestyle. Because serotonin, which has a calming effect and is they have neglected their diet for long time, important for proper sleep. It is found in foods addicts experience gastrointestinal disorders such such as , and sunflower seeds, as well as diarrhoea, constipation and an inability to digest as turkey meat. Increased intake of tryptophan foods properly, along with a poor appetite. As has been shown to stabilise mood, improve sleep a result, they have a special need for foods that and reduce frequency and severity of alcohol are high in nutrients to rebuild damaged tissues withdrawal symptoms (Sahley & Birkner, 2001; and organs and to regain appropriate functioning Bonner et al , 2004). Additionally, a small pilot study of the various systems including the nervous and reported tryptophan supplementation to ameliorate gastrointestinal systems (Battaglia, 2008). cognitive functions, particularly visual memory, in Carefully selected nutrition with the right types of abstinent chronic alcohol abusers (Grotzkyj-Giorgi high and high foods can make et al, 2009). Tryptophan is metabolised along a big difference in coping with cravings during the three metabolic pathways. Serotonin and early stage of recovery (Bonner et al , 2004). There are pathways are physiologically relevant because

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they produce an important to tryptophan supplementation improved (serotonin) and sleep / cognitive outcomes and increased the level of (melatonin). However, serotonin and melatonin neuroprotectant (Grotzkyj-Giorgi pathways of tryptophan account only et al , 2009). for ~10% of tryptophan degradation (Badawy, In summary, amino acid therapy together 2002). In fact, more than 90% of dietary with multivitamin and mineral supplementation tryptophan is metabolised along the - should be considered during the early stages nicotinic acid pathway (Badawy, 2002). The of alcohol and drugs recovery and possibly kynurenine-nicotinic acid pathway produces a continued by following a . number of physiologically active metabolites, No drug currently in wide use – medical collectively known as . Kynurenines or recreational – addresses the root cause of are neuroactive molecules, with some of them neurotransmitter imbalance. Medical drugs causing damage to the brain (kynurenine, merely stimulate temporary excessive release of ) and some others protecting pre-existing neurotransmitter stores or block the (kynurenic acid). Kynurenines act on action of adrenalin, for example. They do not n-methyl-D-aspartate (NMDA) and nicotinic increase the production of neurotransmitters. acid (NA) receptors. NMDA receptors are How can they, without supplying the building particularly important because it is involved materials – the amino acids? Optimising the in the process of long-term potentiation and intake of the relevant amino acids, vitamins, depression, two physiological mechanisms minerals and essential fatty acids is the long-term involved in modulating learning behaviour and way out of addiction. memory formation (Sweatt, 2003). Several animal However important a correct amino acid and studies have indicated that chronic and acute multivitamin supplementation might be, it should alcohol use interferes with tryptophan-serotonin be remembered that nutritional supplementation metabolism (Badawy & Evans, 1973). Acute and is not an instant cure-all. This therapy is not a chronic alcohol abuse increases cerebral serotonin substitute for good nutrition or other aspects concentration (LeMarquand et al , 1994a; 1994b). of healthy living (exercise, relaxation etc). That During alcohol withdrawal, cerebral serotonin is why it is called supplementation and not concentrations drop dramatically (Badawy et substitution. Indeed, increased amino acid intake al , 1980), thus increasing possibility of alcohol should be included into a wider nutritional strategy withdrawal symptoms. Recent research indicates including the right intake of micronutrients that alcohol withdrawal symptoms may be (vitamins and minerals) and macronutritients caused by decreased serotonin levels but also by (low glycaemic index carbohydrates, good quality kynurenines. Kynurenines concentration during proteins and fatty acids) and water. alcohol withdrawal increases, particularly those Good quality proteins can be sourced from with neurotoxic activities (Morgan, 1991). fish, and oily fish has an added bonus: it provides Tryptophan supplementation during early polyunsaturated fatty acids (PUFAs or omega stages of alcohol detoxification may reduce the fats). PUFAs are essential fatty acids (they must number and intensity of withdrawal symptoms come from the diet). Omega fats (omega-3 and possibly improve cognitive functions of and omega-6 fatty acids) are building blocks of abstinent chronic alcohol abusers (Grotzkyj- cerebral membranes together with phospholids Giorgi et al , 2009). A pilot study reported and cholesterol. Their presence is essential to tryptophan supplementation to reduce alcohol maintain membrane fluidity. Membrane fluidity, withdrawal symptoms by acting on kynurenine in turn, guarantees a correct signal transduction pathway of tryptophan metabolism (increase of in the synapses. Most addictive substances strip neuroprotective kynurenine) and to ameliorate the brain of essential fats. Research has shown cognitive functions, particularly visual memory, that relapses among cocaine- and alcohol- in 60 abstinent chronic alcohol abusers enrolled in dependent people over the course of two years a detoxification programme (Grotzkyj-Giorgi et was significantly lowered with an increased al , 2009). Concentrations of the neuroprotective intake of omega-6 and omega-3 foods (Buydens- kynurenine kynurenic acid increased after Branchey et al , 2003a; 2003b). Equal quantities tryptophan supplementation. This study also of omega-6 and omega-3 essential fats should demonstrated that adding selected micronutrients be introduced with the diet as higher intake of (B-vitamins, antioxidant vitamins and minerals) omega-6 fats has been linked to a host of diseases,

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among them chronic abstinence symptoms infusion of high-concentration thiamine, (also linked to omega-3 deficiency) (Holford et symptoms quickly subside and permanent brain al , 2008). impairment is avoided (Bonner, 2006). Among micronutrients, B-vitamins and Generally, the B complex is essential antioxidant vitamins (A, E and C) are particularly for the overall cerebral cognitive performance important because they play crucial roles in brain (Bonner et al , 2004) as a lack of pyridoxine (vitamin physiology. The latter protect the brain from B6) and (vitamin B2) overloads the the attacks of free radicals. These are a natural gamma-amino butyric acid (GABA) shunt, thus byproduct of the endogenous metabolism for resulting in an excess of glutamate production which the body is protected by endogenous and and neuronal death caused by a glutamate exogenous mechanisms. Endogenous antioxidant overexcitement (excitotoxicity). system includes and other enzymatic Thiamine, together with the other vitamins systems. Exogenous, diet-derived are B, vitamins A, C, E and zinc, form a complex the vitamins A, E and C. Unfortunately, brain network of exogenous (diet-derived) antioxidant cells require more diet-derived antioxidants than protection, which has been demonstrated to be other organs because they are low in antioxidants essential in preventing age-related and alcohol- defences (Zaidi et al , 2004) so high intake of caused neurodegeneration, by acting in close antioxidants is amenable to protecting our brain collaboration with the endogenous antioxidant from free radicals attack. protection systems, such as the glutathione system However, both antioxidants systems (Casadesus et al , 2002; Esposito et al , 2002). require substrate molecules derived from food In summary, whatever the addiction, nutrition (glutathione is synthesised from three amino should be considered a powerful ally in the acids). As a part of the intracellular, diet-derived process of recovery, particularly during the initial antioxidant network, vitamin C acts in concert stages of detoxification. A varied diet rich in with other low-molecular-weight compounds, good carbohydrates, good quality proteins (lean including glutathione and vitamin E, as well as meat, fish and vegetable proteins), fresh fruit antioxidant enzymes (Cohen, 1994). To date, an and vegetables, essential fats (oily fish, nuts) and increasing body of evidence reports vitamin C plenty of water should be considered and utilised as playing an important role in the antioxidant as a tool to help the recovery process. network in the brain (Spector & Lorenzo, Food provides the vast majority of metabolic 1973; Grunewald, 1993). Particularly, it has been co-factors essential for the correct functioning suggested that vitamin C plays an essential role in and recovery of brain structures, an example of protecting extracellular compartment from free which can be the case of Wernicke-Korsakoff radicals attack (Rice, 2000). encephalopathy. This is just one example of Alongside the exerted by how (mal)nutrition can play a big role in the endogenous antioxidant enzymes, micronutrients development and perpetuation of brain and (vitamins and minerals) are particularly important cognitive dysfunctions often observed in addicts, to protect neurobiological structures associated and how simple changes in dietary habits (or, in with reward pathways and cognitive functions. more serious cases, nutritional supplementation) Particularly, vitamin B1 (thiamine) plays a central may produce a big difference in mental well- role in preventing the development of Wernicke- being and in recovery of brain functions during Korsakoff psychosis, a neurodegenerative disorder alcohol and drugs recovery. affecting mainly alcoholics (Cook et al , 1998; Thomson et al , 2002; Bonner et al , 2004). People References with Korsakoff syndrome suffer from severe Badawy AA-B (2002) Tryptophan metabolism in memory impairments. Memory dysfunction is alcoholism. Nutrition Research Reviews 15 (1) 123– 152. a very debilitating condition; fortunately, while Badawy A & Evans M (1973) Tryptophan pyrrolase Korsakoff syndrome is a virtually irreversible in ethanol administration and withdrawal. Advances in condition, the prodromal stage of it, Wernicke Experimental Medicine and Biology 35 105–123. encephalopathy, is a reversible condition caused by a marked deficiency of the water-soluble Badawy A, Punjani NF, Evans CM & Evans M (1980) Inhibition of rat brain tryptophan metabolism by ethanol vitamin thiamine (vitamin B1). When blood withdrawal and possible involvement of the enhanced concentration of thiamine is brought back to tryptophan pyrrolase activity. Biochemical Journal 192 physiological levels with a rapid intravenous 449–455.

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