Mental health is EVERY dietitian's business!

Every dietitian will encounter clients or patients with mental ill-health at some point in their working life, especially since the COVID-19 pandemic and associated increases in rates of mental health conditions.1, 2 Mental health conditions often occur alongside other health conditions,3 and current statistics indicate that half of all Australians will experience some form of mental illness in their lifetime.4 This makes mental health every dietitian's business. Dietitians upskilled in mental health are well positioned to be able to undertake dietary assessment, and offer effective early(ier) intervention and/or appropriate referrals. Dietitians are health professionals qualified in clinical, food service, community and public health nutrition and should play pivotal roles in multi-disciplinary mental health care teams. However, in many cases dietitians are not part of the mental health care team and other health professionals do not consider or prioritise food patterns, food security or malnutrition early enough in the treatment process, or understand the impact these can have on overall health and wellbeing. Findings from the Global Burden of Disease Study highlight the impact of suboptimal dietary intake on chronic disease morbidity and mortality.5 This includes 11 million global deaths in 2017 attributed to dietary risk factors including high sodium, and low whole grain and fruits consumption. In the context of mental health specifically, evidence demonstrates the interrelationship of dietary intake and mental health.6, 7 That is, dietary intake influences mental health, and in reverse, mental health affects dietary intake. Observational studies demonstrate an association of healthier dietary patterns (e.g. characterised by higher fruit and vegetable, and omega-3 fatty acids consumption) with a lesser likelihood of disorders including depression and anxiety, and the opposite association for unhealthy dietary patterns (e.g. characterised by high fat and sugar consumption).8, 9 Further, intervention studies have demonstrated improvement in mental health outcomes including depression levels and psychotic symptoms, following dietary intervention such as those focusing on whole of diet and omega-3 fatty acid, pre- and pro-biotic supplementation.10-13 There is still much to be explored in terms of the directionality of effects between diet and mental health, and associated diet-related diseases, however the fact that an association exists is clear. This supports the need for dietitian involvement in mental health care, while guidelines such as the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders14 recommend that lifestyle options including diet should form the first-line treatment strategy for mood disorders. People living with mental illness are more likely to have poor dietary intakes, poor hydration status, irregular food intake and food insecurity,15-18 yet nutrition is not standard in care plans. Poor diet quality, often characterised by foods high in energy and sodium and low in essential nutrients, can contribute to chronic disease including cardiovascular disease and diabetes, and is prevalent in people across the spectrum of mental illness, but particularly those with severe mental illness.15, 19 Individuals with mental illness may not access information about dietary intake, or those that do may source this information online where misinformation is common and, for some, is hard to discern from evidence-based information, or from health professionals who have low confidence in providing dietary information.20 Mental illness impacts society as a whole, and is associated with significant economic costs.21 National spending on mental health-related services in Australia reached $11 billion in 2019–2020, while on an individual level, healthcare costs significantly increase for individuals with mental illness and other comorbidities.21 Approximately 94% of Australians with a mental or behavioural condition have a comorbid long term health condition.22 Common comorbidities in people with mental illness include obesity, cardiovascular disease, respiratory disease, and diabetes.23 These conditions have established dietary interventions as evidenced in their respective best practice clinical guidelines.24-27 Early intervention prevents progression and enhances the management of these illnesses for which dietary intervention is fundamental, as well as reducing healthcare costs. Many groups are particularly vulnerable and experience increased risk of mental illness and associated comorbidities. These groups include for example veterans,28 people with disordered eating,29 people with a disability,30 Aboriginal and Torres Strait Islander Peoples,30 young people,30 older people,31 people of cultural and linguistic diversity,32 the LGBTQIA+ community,33 victims of domestic violence and sexual assault,34 and people in rural and remote communities,35 among many others. These groups represent people who are at greater risk of mental illness, comorbid physical illness, early ageing and suicide. When you consider other risk factors such as socioeconomic status and education,36 many are less likely to have nutrition and food skills. In summary, dietitians can deliver effective, evidence-based dietary interventions to improve symptoms of mental illness and to prevent, treat and manage the physical illnesses associated with mental illness.37, 38 Dietitians working in mental health are highly equipped with assessment to screen for poor diet once mental ill health is recognised, to allow for timely and early intervention, monitoring and evaluation, counselling and psychoeducation skills, in addition to extensive behaviour and lifestyle modification techniques to help people living with mental illness. However, they continue to be under-recognised and underutilised. In this issue of Nutrition & Dietetics, a range of differing conditions, outcomes, screening tools and population groups within an overarching mental health context are considered. This issue includes scoping reviews that synthesise the evidence to show promising outcomes in terms of effectiveness and cost effectiveness of dietary interventions for a range of conditions,13, 39 as well as a scoping review highlighting the need for validated nutrition risk screening tools in people with severe mental illness.19 Further, a systematic review found the therapeutic relationship between client and dietitian is a valued and multifactorial component of clinical dietetic practice.40 Studies also explored associations between nutritional status and caregiver burden in Alzheimer's Disease,41 the influence of the COVID-19 pandemic on body image in LGBTQ+ individuals,42 the prevalence of food insecurity among community-dwelling individuals with severe mental illness,17 the influence of gender dysphoria in eating disorders among gender diverse individuals,43 nutritional intake and food service satisfaction of adults in specialist inpatient mental health services,18 and the issue of disordered eating among nutrition and dietetic students.44 This issue of Nutrition & Dietetics allows for opportunities to upskill in mental health through increasing awareness of the realities and implications of good nutrition.