Nutritional counseling needs of patients with mental disorders in psychiatric care: A cross-sectional survey

Abstract

Background:

The exploration of diet and nutrition as they relate to mental health and psychiatric disorders is a developing field. Anxiety, depression, and pharmacological treatments used to treat these disorders are likely to have side effects that induce decreases in activity and irregular eating habits, resulting in persistent nutritional imbalance. Unhealthy dietary patterns are associated with an increased risk of developing physical and mental health conditions. Despite this, nutritional support to patients in psychiatric care is not adequate.

Aims:

This study aimed to determine the factors underlying the need for nutritional counseling among patients with a mental disorder in psychiatry. The factors explored are eating-related symptoms, eating behavior, interest in food, seeking nutritional counseling, and impact on quality of life (QOL).

Methods:

We utilized a cross-sectional study design. Eligible patients were asked to complete a questionnaire regarding physical measurements and nutritional counseling. In addition, patients’ diagnoses and blood test data were referenced from their medical records. The analysis focused on two groups: those who desired to consult a nutritionist and those who did not.

Results:

Ninety-three patients completed the study. The nutritional status and need for nutritional counseling in psychiatry patients indicates that patients with dietary problems requested nutritional counseling (p < .001). Patients who were more likely to need nutritional counseling had lower QOL in daily life (p = .011), pain/discomfort (p = .024), and anxiety/depression (p = .010) on the EuroQol 5-Dimension 5-level (EQ-5D-5L).

Conclusions:

Patients with mental disorders who need nutritional counseling tend to have food-related problems and low QOL. It is necessary to establish an interdisciplinary system for nutritional counseling.

Keywords

Mental disorder psychiatry nutritional counseling lifestyle quality of life

Introduction

Mental health and lifestyle

The exploration of diet and nutrition as they relate to mental health and psychiatric disorders is a developing field. Mental health status includes mental disorders, psychosocial disorders, and other mental conditions associated with severe distress or disability. In an increasingly complex society, in 2019, one in every eight people, or 970 million people worldwide, were living with a mental disorder, with anxiety and depressive disorders being the most common (GBD 2019 Mental Disorder Collaborators, 2022; Patel et al., 2018). Additionally, the medical costs for mental disorders are rising. In recent years, with the development of psychotropic drugs, it is possible to control mental health symptoms with medication while partaking in social activities. World Health Organization (WHO) states that patients need to be supported in leading an appropriate lifestyle and taking their medications to maintain their participation in social activities. Building patients’ individual competence includes interventions designed to change behaviors that undermine their physical and mental health. Low levels of physical activity and unhealthy dietary patterns are associated with increased risk of both physical and mental health conditions (Jacka et al., 2014; WHO, 2021a, 2021b).

Side effects of medications affecting nutritional status

Anxiety, depression, and medications used to treat these disorders are likely to have side effects that induce decreases in activity and irregular eating habits, resulting in a persistent nutritional imbalance. Atypical antipsychotics for schizophrenia have been associated with increased body mass index (BMI) and blood cholesterol, yet there are no nutrition guidelines (Aucoin et al., 2020; Rognoni et al., 2021). An indifference to food, anxiety, and stress may lead to decreased or increased appetite, leading to increased or decreased eating. This would then lead to malnutrition or excessive weight gain, which can reduce the effectiveness of mental health treatment. However, the side effects of medications for severe mental health conditions can play a role in premature mortality by contributing, for example, to obesity, glucose intolerance, and dyslipidemia (WHO-Western Pacific Region, 2022).

Nutritional support for mental disorders

Patients with mental disorders have been reported to have a lower quality of life (QOL) (Abbott et al., 2020; Lehman, 1983). A relationship between eating and mental disorders has been established, as typified by eating disorders (Sarris et al., 2015; Treasure et al., 2020). Diet and nutrition offer key modifiable goals for preventing mental disorders (Sarris et al., 2015). Diet and nutrition are not only critical for individuals’ physiology, but they also have an effect on mental well-being (Adan et al., 2019). Further, diet quality may be a modifiable risk factor for mental illness (Marx et al., 2017). Nutritional psychiatry provides new insights into the treatment of mental disorders (Goh & Lim, 2021) and is a rapidly growing field of study with the potential to provide clinically meaningful interventions for both the prevention and management of mental illness (Marx et al., 2017). The impact of diet and nutrition on mental health provides emerging evidence of the key role of nutrition in the onset, symptomatology, and treatment of mental disorders, particularly anxiety and depression (Merlo & Vela, 2022).

Nutritional support for patients in psychiatric care is inadequate. Research has examined the effects of nutritional supplements and deficiencies associated with mental disorders (Carnegie et al., 2020; Marx et al., 2021; Sarris, 2019), the lifestyle intervention by diet quality in psychological depression (Brierley et al., 2021), and the role of dietary interventions to prevent depression (Lassale et al., 2019). However, few studies have addressed the diets of patients in psychiatric care, and effective support methods to assist such patients and improve their QOL have not been identified. Furthermore, even when patients have the necessary dietary and nutritional knowledge, they may have difficulty changing their eating habits after discharge if they do not perceive a need or lack support to change their behavior.

Thus, this study intended to clarify whether psychiatric patients perceive themselves as having a desire for nutritional counseling and what food-related problems they are experiencing. Further, this study aimed to determine the factors underlying the need for nutritional counseling among patients with mental disorders in psychiatric care. We explored the factors of eating-related symptoms, eating behavior, interest in food, seeking nutritional counseling, and impact on QOL. This was a novel study of the nutritional counseling needs of patients with mental disorders. The enhancement of nutritional counseling suited to each patient’s context could contribute to improving QOL in this population.

Methods

The study was a cross-sectional study. The survey was conducted at multiple psychiatric hospitals within the major cities of Japan between June 2019 and April 2020. Eligible patients were asked to complete a questionnaire regarding physical measurements and nutritional counseling. Additionally, patients’ diagnoses and blood test data were referenced from medical records.

Participants

Both patients admitted to psychiatric hospitals and outpatient day programs were included in the study. In Japan, the medical system is such that outpatient and inpatient admissions are often repeated periodically, so we did not distinguish between inpatient and outpatient admissions. Based on the inclusion and exclusion criteria, and in accordance with medical and ethical considerations, patients were referred to the study by their physicians during the eligible patient recruitment phase. The researcher, using an explanatory document, explained the purpose of the study to patients who were interested in participating and obtained their informed consent in writing. All data were collected and analyzed using study numbers. The data were anonymized in a linkable and traceable manner, in case it was necessary to identify individuals in the course of medical treatment.

Eligibility criteria

Patients with the following criteria were included in the study:

Hospitalized patients or those attending outpatient day programs who had a mental illness

Patients who obtained the permission of the attending physician and their nurse

Patients who were able to provide informed consent

Medical and ethical considerations

Patients with the following symptoms were excluded from the study:

Patients sensitive to ambient stimuli who were admitted into a protective room

Patients on suicide watch

Patients with severe neurological symptoms such as epilepsy or convulsions

Patients with communication difficulties

Patients with unstable psychiatric symptoms, where self-harm or harm was a risk

Patients for whom the study could induce suicidal symptoms or aggravate psychiatric symptoms

Patients with impulse control problems and difficulty predicting violent behavior

The Institutional Review Board of the Medical Research Ethics Committee of Onda-daini hospital (no. onR-0005) approved this study. The survey began after registering this study as a clinical trial (UMIN registration no.000037178, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000042366).

Anthropometers

Body measurements, body weight, BMI, body fat percentage, muscle mass, and estimated bone mass were analyzed using a body composition analyzer (TANITA InnerScan50 BC308) and a performance assessment. Performance status rated the physical activity of the medical patients on a 5-point scale:

0: Fully active, able to carry on all pre-disease performance without restriction

1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g. light housework and office work).

2: Ambulatory and capable of all self-care but unable to carry out any work activities; up and active for more than 50% of waking hours

3: Capable of only limited self-care; confined to bed or chair more than 50% of waking hours

4: Completely disabled; cannot carry on any self-care; totally confined to bed or chair

Medical records

Age, sex, diagnosis, medication usage, life circumstances and background (e.g. type of insurance and educational history), and biochemical test values (e.g. blood lipids, blood glucose, and blood pressure) were obtained from medical records. In Japan, the design of the welfare system means that there is no disparity in available medical care. Therefore, we used the economic status of individuals as an indicator of receiving welfare. Psychotropic drugs were analyzed by class separately.

Questionnaire

The following questionnaires were used with the participants:

(1) Nutritional status and Need for nutritional counseling in Psychiatry patients (NNP)

The NNP was originally developed for patients with psychiatric disorders, based on the international indexes Patient-Generated Subjective Global Assessment Short Form (Balstad et al., 2019) and Mini Nutritional Assessment-Short Form (Holvoet et al., 2020), which are subjective nutrition assessment forms. NNP is set as questions including eating-related symptoms and nutritional counseling needs with 15 items: five questions each on ‘eating behavior’, ‘interest in food’, and ‘seek nutritional counseling’.

QOL assessment: EuroQol 5-Dimension 5-level (EQ-5D-5L; Shiroiwa et al., 2021)

The EQ-5D-5L consists of five dimensions (‘mobility’, ‘self-care’, ‘usual activities’, ‘pain/discomfort’, and ‘anxiety/depression’), with each dimension having five levels. The Visual Analogue Scale (VAS) is a 0 to 100 scale that asks patients to describe their overall health on the day they complete the questionnaire. Quality-adjusted life year (QALY) is an index used to evaluate patients’ QOL and quantity of life lived, where perfect health is represented as ‘1’ and death as ‘0.’ QALY was calculated from and converted via the EQ-5D-index, according to the user manual.

Statistical analysis

The analysis focused on two groups: those who desired to consult a nutritionist and those who did not need to. Statistical analysis was performed using the Mann-Whitney U test or the χ² test using SPSS 28 (IBM).

Results

The survey was conducted between June 2019 and April 2020 for all patients receiving inpatient care and outpatient day program care in the psychiatry department. Ninety-four patients who met the inclusion criteria were recruited to participate in the study, but one could not continue to completion due to deteriorating health. Ninety-three patients completed the study, representing 51 men and 42 women, and 67 inpatients and 27 outpatients in the day program (Figure 1).

Figure 1.

Study flowchart.

Table 1 shows the demographics and characteristics of the patients. Schizophrenia was the most common diagnosis. The median age for male patients was 53 years old (IQR 40–63), and their median BMI was 22.8 kg/m² (IQR 21.6–26.0). The median age for female patients was 57 years old (IQR 48–70), and the median BMI was 24.3 kg/m² (IQR 20.8–27.5). Anthropometric data were from the day of the survey, and blood tests were referenced from the most recent medical records. Table 2 shows the relationship between clinical examination and medication status for needing nutritional counseling. Antipsychotics were not used alone with typical antipsychotics, but mostly in combination with second-generation antipsychotic drugs. Table 3 presents eating-related symptoms, and Table 4 presents NNP and QOL (EQ-5D-5L) categorized into two groups – needing or not needing nutritional counseling. The NNP gives a total score that scores eating habits, interest in food, and nutritional counseling seeking, with higher scores indicating patients have more problems with diet and nutrition.

Table 1.

Patients’ demographics and characteristics.

Variables		Male (n = 51)	Female (n = 42)
Age: years (median [range])		53 (23–78)	57 (25–77)
Diagnosis n (%)
Schizophrenia		39 (76.5)	30 (71.4)
Major depression		5 (9.8)	2 (4.8)
Bipolar disorder		1 (2)	6 (14.3)
Schizoaffective disorder		3 (5.9)	1 (2.4)
Delusional disorder		–	1 (2.4)
Acute and transient psychotic disorder		1 (2)	–
Organic mental disorder		–	1(2.4)
Some other disorder that was not listed		2 (3.9)	1(2.4)
Economic status n (%)
Low (receiving public assistance)		23 (45.1)	19 (45.2)
Cohabitation n (%)
Alone		18 (35.3)	23 (54.8)
Family		25 (49.0)	14 (33.3)
Group homes		7 (13.7)	5 (11.9)
Marital status n (%)
Married		6 (11.8)	6 (14.3)
Unmarried		36 (70.6)	19 (45.2)
Other (separation/divorce/bereavement)		7 (13.7)	17 (40.5)
Education n (%)
High school graduate or above		38 (74.5)	29 (69.0)
Employment status n (%)
Employed		4 (7.8)	1 (2.4)
Clinical examination	Measure	Median (IQR 25%–75%)	Median (IQR 25%–75%)
BMI	kg/m²	22.8 (21.6–26.0)	24.3 (20.8–27.5)
Body fat	%	22.0 (17.0–25.8)	33.5 (28.9–40.8)
Muscle mass	kg	49.3 (45.1–55.5)	36.4 (33.7–39.6)
Bone mass	kg	2.8 (2.5–3.0)	2.2 (2.0–2.5)
Basal metabolic expenditure	kcal	1,446 (1,294–1,632)	1,151 (1,030–1,279)
Body water content	kg	51.8 (45.6–55.4)	45.1 (39.9–50.4)
Alb	g/dl	4.0 (3.8–4.5)	4.0 (3.7–4.2)
TG	mg/dl	88.0 (63.5–117.0)	98.0 (70.8–155.8)
TCh	mg/dl	183.0 (163.5–198.5)	199.5 (172.8–234.8)
LDL	mg/dl	109.0 (83.3–122.3)	115.5 (92.8–143.3)
BS	mg/dl	91.0 (83.5–100.0)	89.5 (84.0–107.5)
TP	g/dl	6.7 (6.2–7.3)	6.7 (6.3–7.0)
AST	U/l	16.0 (14.0–21.0)	17.0 (13.8–20.0)
ALT	U/l	17.0 (12.5–21.0)	15.5 (11.0–23.3)
γGTP	U/l	21.0 (14.0–27.5)	17.0 (14.0–26.0)
BUN	mg/dl	11.0 (9.0–14.5)	10.0 (8.0–14.3
WBC	ml	5,500 (4,900–6,400)	5,500 (4,750–7,400)
RBC	10⁴/µl	439 (417–481)	419 (393–444)
Hb	g/dl	13.7 (12.8–14.9)	12.6 (12.1–13.3)
Ht	%	41.6 (39.2–44.3)	38.9 (36.1–41.5)
Systolic blood pressure	mmHg	121 (110–131)	123 (115–130)
Diastolic blood pressure	mmHg	78 (68–89)	76 (70–84)
PS		1 (1–2)	2 (1–2)

Note. BMI = body mass index; Alb = albumin; TG = triglyceride; TCh = total cholesterol; LDL = low-density lipoprotein cholesterol; BS = blood sugar; TP = total protein; AST = aspartic acid transaminase; ALT = alanine aminotransferase; γGTP = gamma-glutamyl transpeptidase; BUN = blood urea nitrogen; WBC = white blood count; RBC = red blood count; Hb = hemoglobin; Ht = hematocrit; PS = performance status.

Table 2.

Comparison of clinical examination and medication status for needing nutritional counseling.

Variables	Need for nutritional counseling (n = 36)	Not need for nutritional counseling (n = 57)	p-value^†
Variables	n (%)	n (%)	p-value^†
Diagnosis
Schizophrenia	27 (75.0)	42 (73.7)	.368
Major depression	4 (11.1)	3 (5.3)
Bipolar disorder	2 (5.6)	5 (8.8)
Schizoaffective disorder	0 (0.0)	4 (7.0)
Delusional disorder	1 (2.8)	0 (0.0)
Acute and transient psychotic disorder	0 (0.0)	1 (1.8)
Organic mental disorder	0 (0.0)	1 (1.8)
Some other disorder that was not listed	2 (5.6)	1 (1.8)
Inpatients (n = 66)	21 (58.3)	45 (79.0)	.038*
Day-care outpatients (n = 27)	15 (41.7)	12 (21.0)	.038*
Variables	Median (IQR 25%–75%)	Median (IQR 25%–75%)
Age (years)	53.0 (45.0–62.8)	56.0 (44.5–68.0)	.355
BMI (kg/m²)	24.1 (21.2–27.3)	22.8 (21.5–26.4)	.396
Performance status	1.0 (1.0–2.0)	2.0 (1.0–2.0)	.036*
Body fat (%)
Male	21.5 (16.3–25.7)	22.0 (17.6–26.4)	.798
Female	32.8 (26.9–37.9)	35.1 (29.1–44.3)	.477
Body mass (kg)
Male	51.0 (47.9–57.1)	48.0 (44.2–54.5)	.094
Female	37.8 (34.9–39.1)	35.8 (33.7–40.1)	.731
Body bone (kg)
Male	2.9 (2.7–3.1)	2.6 (2.5–3.0)	.032*
Female	2.4 (2.1–2.5)	2.2 (2.0–2.6)	.673
Alb	4.0 (3.7–4.4)	3.9 (3.7–4.3)	.531
TG	88.0 (71.0–117.0)	97.0 (63.3–153.0)	.848
TCh	188.0 (170.0–202.0)	188.5 (163.3–213.5)	.800
LDL	113.0 (98.0–130.0)	111.0 (84.0–137.0)	.947
BS	90.0 (81.0–102.0)	91.0 (85.0–101.5)	.366
Psychotropic drugs usage	n (%)	n (%)
Antipsychotic medication (n = 83)	32 (88.9)	51 (89.5)	1.000
Antidepressant medication (n = 23)	9 (25.0)	14 (24.6)	1.000
Minor tranquilizer medication(n = 25)	11 (30.6)	14 (24.6)	.632
Sleeping medication (n = 56)	23 (63.9)	33 (57.9)	.665
Antiparkinsonian medication (n = 24)	11 (30.6)	13 (22.8)	.469
Antiepileptic medication (n = 29)	12 (33.3)	17 (29.8)	.819

Note. BMI = body mass index; Alb = albumin; TG = triglyceride; TCh = total cholesterol; LDL = low-density; BS = blood sugar.

†

Mann-Whitney U test or Fisher’s Exact test

p < .05.

Table 3.

Comparison of clinical examination in needing nutritional counseling (objective assessment).

Eating-related symptoms	Needing nutritional counseling (n = 36) n (%)	Not needing nutritional counseling (n = 57) n (%)	p-value^†
Anorexia	8 (8.6)	9 (9.7)	.583
Excessive appetite	13 (14.0)	16 (17.2)	.493
Nausea	5 (5.4)	9 (9.7)	1.000
Vomiting	2 (2.2)	2 (2.2)	.639
Constipation	11 (11.8)	16 (17.2)	.818
Diarrhea	7 (7.5)	17 (18.3)	.334
Dysgeusia	4 (4.3)	4 (4.3)	.706
Olfactory abnormality	6 (6.5)	3 (3.2)	.084
Dysphagia	8 (8.6)	5 (5.4)	.122
Early satiety	9 (9.7)	11 (11.8)	.607
Fatigue	24 (25.8)	28 (30.1)	.134
Pain	19 (20.7)	20 (21.7)	.085

†

χ² test.

Table 4.

Comparison of NNP and QOL in need for nutritional counseling (subjective assessment).

Variables	Needing nutritional counseling (n = 36)	Not needing nutritional counseling (n = 57)	p-value^†
Variables	Median (IQR 25%–75%)	Median (IQR 25%–75%)	p-value^†
Eating behavior
I eat alone.	2.0 (1.0–4.0)	1.0 (1.0–2.5)	.003
I cannot get food down my throat.	1.0 (1.0–1.0)	1.0 (1.0–1.0)	.360
I have an appetite and overeat.	1.0 (1.0–3.0)	1.0 (1.0–2.5)	.325
I buy sweets and snacks	2.0 (1.0–3.0)	2.0 (1.0–3.0)	.496
I drink juice	3.0 (2.0–4.0)	3.0 (2.0–4.0)	.739
Interest in food
I don’t enjoy eating.	1.0 (1.0–2.0)	1.0 (1.0–2.0)	.734
I don’t feel hungry	1.0 (1.0–2.0)	1.0 (1.0–2.5)	.962
I don’t want to spend money on food	2.0 (1.0–3.8)	1.0 (1.0–2.0)	.065
I am particular about eating	2.0 (1.0–4.0)	1.0 (1.0–2.0)	.007*
I take care of my meals more than others	2.0 (1.0–4.0)	1.0 (1.0–1.0)	.001*
Seek nutritional counseling
I would like to attend a cooking class	2.0 (1.0–3.8)	1.0 (1.0–2.0)	.013*
I would like to consult someone about my diet	2.0 (2.0–4.0)	1.0 (1.0–1.0)	.001*
I want to know about nutritional balance	3.0 (2.0–4.0)	1.0 (1.0–2.0)	.001*
I am worried about my diet	2.5 (1.0–4.0)	1.0 (1.0–1.0)	.001*
I would like to consult a nutritionist	2.0 (2.0–3.0)	1.0 (1.0–2.0)	<.001*
Total score	33.00 (29.0–37.75)	24.00 (22.0–29.00)	<.001*
EQ-5D-5L
Mobility	1.00 (1.00–2.00)	1.00 (1.00–1.00)	.235
Self-care	1.00 (1.00–1.00)	1.00 (1.00–1.00)	.226
Usual activities	1.00 (1.00–2.00)	1.00 (1.00–1.00)	.011*
Pain/discomfort	2.00 (1.00–3.00)	1.00 (1.00–2.00)	.024*
Anxiety/depression	2.00 (1.00–3.00)	1.00 (1.00–2.00)	.010*
Visual analog scale (VAS)	60.00 (44.25–73.75)	70.00 (52.50–80.00)	.075
EQ-5D-index (QALYs: Quality-adjusted life years)	0.73 (0.61–0.83)	0.81 (0.74–1.00)	.009*

Note. The higher the points on the score meter, the more problems are present. EQ-5D-5L = EuroQol 5-Dimension 5-level

†

Mann-Whitney U test

p < .05.

Patients with better physical performance on the objective assessment (p = .036) and outpatients in day programs (p = .038) were more likely to seek nutritional counseling. The NNP indicates that patients with dietary problems requested nutritional counseling (p < .001). Higher scores on the EQ-5D-5L indicate lower QOL, while lower scores on the VAS indicate lower QOL. Patients who were more likely to need nutritional counseling had lower QOL in daily activity (p = .011), pain/discomfort (p = .024), and anxiety/depression (p = .010) on the EQ-5D-5L. The VAS returned a median score of 60 points vs. 70 points for those needing and not needing nutritional counseling, respectively, with patients who needed nutritional counseling having a lower QOL (p = .075). The median QALYs converted by the EQ-5D-index was 0.73 for those who needed nutritional counseling and 0.81 for those who did not, indicating that patients who need nutritional counseling had significantly lower QOL (p = .009). However, there was no significant association between biochemical tests and symptoms related to nutritional intake on the need for nutritional counseling. Additionally, a comparison of inpatient and outpatient day program visits showed no significant differences.

Discussion

To our knowledge, no previous studies have investigated the nutritional counseling needs of patients with mental illness. The new approach focusing on ‘diet and nutrition’ in psychiatric treatment may serve to bridge the gap between treatment as medicine and patients’ lifestyle.

This study suggests that patients, who perceive a problem with their diet and have a low QOL, tend to need nutritional counseling. However, the lack of a perceived need for nutritional counseling indicates the necessity of healthcare professionals arranging nutritional counseling and providing dietary modifications in the presence of dietary-related problems. Patients with schizophrenia accounted for 70% of the patients in this study. Nutritional counseling for patients with schizophrenia should (1) be communicated concretely, such as shopping choices, because they have little experience in the real world due to long-term hospitalization; (2) provide nutritional counseling in small steps because of their limited understanding of their illness; and (3) repeated support is necessary because it is difficult to lead to a change in eating behavior. This approach differs between motivated and unmotivated patients who need nutritional counseling. Therefore, effective nutritional counseling needs to be tailored to the patient’s psychopathology and condition. Hence, evidence-based guidelines are needed to make psychiatric nutritional counseling a common practice.

Diet and activity in nutritional counseling

Diet is associated with physical fitness, anxiety, and QOL. Healthcare professionals need to focus their attention on diet in psychiatric care. Currently, nutritional support for mentally disabled patients is not common, but this survey shows that patients will seek nutritional counseling if given the opportunity. A previous study indicated that the quality of and individual’s diet is related to their risk for developing common mental disorders (Jacka, 2017), and dietary improvement may provide an efficacious treatment strategy for managing mental disorders (Jacka et al., 2017).

While patients who reported low daily activities on EQ-5D-5L sought nutritional counseling, patients whose physical performance was evaluated as satisfactory by the medical staff also requested nutritional counseling. This suggests that patients’ subjective perspectives should be considered rather than just being determined through objective nutritional assessments. In previous studies, lifestyle factors in the treatment of mental disorders associated with low physical activity and unbalanced dietary patterns (Firth et al., 2020), insufficient sleep, a poorly balanced diet, snacking between meals, and lack of exercise were significantly associated with the prevalence of depressive symptoms (Furihata et al., 2018). However, there are currently no nutritional guidelines for patients with psychiatric disorders.

Nutritional counseling is not widely adopted in general psychiatry practice. Diet is the foundation of lifestyle, and support for a regular healthy lifestyle, eating habits, and increased activity through nutritional counseling would help prevent lifestyle-related diseases in patients with mental disorders, helping them function better in their social life.

Multidisciplinary collaboration in nutritional counseling

Among patients with mental disorders, those who need nutritional counseling tended to have low QOL, evidenced by their being high in pain/discomfort and anxiety/depression. Patients might have sought nutritional consultation due to compounded anxiety and discomfort rather than a desire to acquire nutritional knowledge. Previous studies showed a connection between schizophrenia and poorer-quality dietary patterns (Aucoin et al., 2020), and showed an association between higher anxiety levels and unhealthy dietary patterns (Aucoin et al., 2021). Dietary interventions are promising as novel interventions for reducing depression symptoms (Firth et al., 2019). Previous studies have reported that emotions such as anxiety and discomfort are associated with help-seeking (Blanch & Barkus, 2021; Heinig et al., 2021; Hohls et al., 2021). Therefore, dietitians should consider patients’ mental health and that patients may have other concerns besides dietary needs. Patients with schizophrenia may not have much of a hand in considering their diet and nutritional balance. Some patients may not be convinced about the treatment plan for schizophrenia or other disorders. Even in such cases, starting with the relatively easy-to-accept treatment of nutritional counseling and building a relationship of trust may lead to the necessary treatment. Furthermore, dietitians should increase their expertise and provide effective nutritional counseling (Opie et al., 2018). Collaboration with psychiatrists, clinical psychologists, mental health workers, and other psychiatric medical staff is also important. Having a table where meals are eaten is an opportunity for social interaction and may reduce anxiety and improve QOL by improving patients’ diet and confidence in their eating habits. A past multimodal intervention involved a self-directed learning program where individuals were guided to make lifestyle changes, including diet, activity, stress management, and mindfulness practices (Abbott et al., 2020). Mental disorders can affect all areas of life, including physical performance, relationships with family and friends, and the ability to participate in the community. Therefore, a multimodal approach involving different professionals in integrating physical, psychological, and social aspects of lifestyle improvement is essential. Nutritional counseling for patients with mental disorders provides a multifaceted intervention that improves healthy eating, which has positive potential implications for treatment.

Limitations

The target population consisted of relatively symptomatically stable patients who met the eligibility criteria, and the possibility that the needs of patients with more serious illnesses were not captured is quite real. Additionally, QOL, at the time of the survey, could not be accurately assessed for patients with unstable feelings, such as those with bipolar disorder. The need for nutritional counseling may have been influenced by the patient’s motivation. For example, delusions, helplessness, self-neglect, impaired motivation, and emotional disturbance can manifest as ‘negative cognitions’ that reduce the likelihood of requesting support. Therefore, patients should receive support for improving their lifestyles, even if they do not wish to receive nutritional counseling. The present study was conducted in Japan, and it is necessary to conduct similar surveys in more countries to further examine the various factors.

Conclusions

Patients with mental disorders need dietary support to help maintain their daily activities in their community and to help them lead healthy lifestyles. Patients with mental disorders who need nutritional counseling tended to have food-related problems and low QOL. However, even when nutritional counseling is necessary based on symptoms and blood test results, patients may not perceive a need for nutritional counseling. Thus, suggestions from healthcare professionals are needed. Currently, there are no nutritional guidelines for mentally disabled patients, and nutritional guidance is not widely available. Therefore, it is necessary to establish a system for nutritional counseling and guidelines. In addition, it is necessary to increase dietitians’ expertise in the field of mental disorders so that they may conduct effective nutritional counseling. In nutrition counseling, in addition to providing support for dietary health and improvement according to patients’ needs, it is necessary to consider patients’ anxiety and QOL, which makes collaboration among multiple professions indispensable.

Footnotes

Acknowledgements

We are deeply grateful to all the patients who kindly participated in this study even though they were undergoing treatment.

Author contributions

Saori Koshimoto contributed to the concept and design of the work, analysis, and interpretation of the data, and drafted the article. Nanae Kuboki, Chihiro Gunji, and Yuuki Oyake contributed to acquisition, analysis data, and revising the article critically for important intellectual content. Mayo Fujiwara, Hitomi Hayashi, and Hiroki Moriya contributed to the design of the work and interpretation of the data. Takashi Takeuchi and Eisuke Matsushima contributed to the concept of the work and revised the article critically for important intellectual content. Katsuya Ohota contributed to the design of the work, acquisition, drafted the article, and revised the article critically for important intellectual content.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Saori Koshimoto

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