How can the benefits of dietetic care be integrated into the treatment of patients undergoing alcohol withdrawal?

Abstract

Patients who present to hospital for alcohol withdrawal present with varying nutritional abnormalities. These may include those identified on pathology testing, such as micronutrient deficiency or electrolyte abnormalities, or may also be identified on physical examination, such as malnutrition or overweight obesity [1, 2]. In a 5-year retrospective audit of admissions relating to alcohol withdrawal at a large tertiary teaching hospital in Australia, there was variable input from the dietitian [1]. This commentary considers the role of the dietitian in the nutritional management of patients admitted to hospital for alcohol withdrawal.

The relationship between excess alcohol consumption and nutrition is complex. Alcohol provides little beyond energy intake (29 kJ/g) and when consumed in addition to other foods or fluids promotes a positive energy balance ultimately leading to weight gain and obesity [3]. Those who consume alcohol in excess generally have poor dietary quality which is further compounded by the effects of excess alcohol on metabolism [2]. In some instances, patients may prioritise alcohol intake over the consumption of other foods resulting in calorie intake but lacking in nutrient intake. Alcohol may also impact on the digestion and absorption of nutrients leading to nutritional deficiency [4]. Therefore, patients undergoing alcohol withdrawal may have both primary and secondary malnutrition, and this may eventually precipitate into protein-energy malnutrition [4]. Literature reporting on rates of malnutrition in alcohol withdrawal in the absence of cirrhosis is limited. In an Australian drug and alcohol treatment unit, 24% of patients were identified as mild/moderately malnourished using the Subjective Global Assessment [2], the most widely used tool to diagnose malnutrition [5]. However, rates of malnutrition differ with severity of liver disease. In a small sample reporting on the prevalence of malnutrition in patients with liver cirrhosis in Australia, 40% of patients were identified as malnourished [6]. However, this study was limited by its small sample size and has not reported on the severity of malnutrition. Internationally, rates of malnutrition in patients with cirrhosis in Nepal reported 43% of patients were mild/moderately malnourished, and 56% were severely malnourished [7]. Significant variance may exist between rates of malnutrition given resource and economic differences that exist geographically and how nutrition care may be provided. Malnutrition is likely to be one of several other nutritional risk factors that may require attention and input from a nutrition professional, such as a dietitian.

Dietitians are nutrition professionals with qualifications and skills to provide expert nutrition and dietary advice, or medical nutrition therapy. Dietitians work in several settings including clinics, hospitals, food industry, sporting bodies, public health, research, education and media [8]. However, differences may exist internationally and across different geographical regions. The Academy of Nutrition and Dietetics (formerly American Dietetic Association) published a statement in 1990 advocating for the role of dietitians in the treatment and recovery from chemical dependency (including alcohol) supporting improved nutritional status throughout detoxification and recovery [9]. However, the role statement that was developed was not implemented, and little has been done to progress the role of the dietitian in addiction treatment, including alcohol withdrawal [10]. While guidelines for the treatment of alcohol related problems refer to the role of nutrition and the importance of monitoring nutritional status, they do not specifically mention dietitians or specific nutrition assessment or screening tools to identify nutritional problems such as malnutrition [11]. With the known risk of nutritional issues for patients who undergo drug and alcohol treatment [2], or more specifically alcohol withdrawal [1], it is clear that further work is needed to clarify the fundamental role of dietitians in improving outcomes.

Dietitians can play a role in the nutritional management of patients admitted to hospital for alcohol withdrawal and provide guidance for care. The potential role of the dietitian being incorporated into multidisciplinary addiction treatment teams has been described [12], however, there is limited guidance on the role of the dietitian in those admitted to hospital for alcohol withdrawal. In most instances admission to an acute hospital for alcohol withdrawal may only be 2–5 days [13], and this may influence the extent of nutrition intervention and education. In some situations, dietitian resourcing and local priorities may not provide emphasis on shorter hospital admissions or engaging with patients with alcohol use disorder (AUD). Perhaps this is related to the absence of nutrition practice guidelines that could provide a guide or minimum standard of nutrition care. During shorter hospital admissions, the dietitian's role in contributing to harm minimisation, supporting health and nutrition may be limited by some of these constraints. For shorter admissions the dietitian's role may focus on screening and managing acute nutritional concerns such as malnutrition and refeeding syndrome while reinforcing harm minimisation aspects of care. This can include the importance of thiamine supplementation, facilitating access to food through non-government organisations and referral to social workers for further assistance, prescribing oral nutrition supplements and considering referral to community dietitian services. Similarly, a dietitian may play a role in outpatient alcohol withdrawal management or provide continued support on discharge from hospital. For example, following up on nutrition interventions such as tolerance to prescribed nutrition supplements and providing ongoing nutrition counselling. The multidisciplinary team including dietitians may best be supported with local practice guidelines to guide interventions including routine screening for micronutrient deficiency and micronutrient supplementation. These could include recommendations on pathology testing such as micronutrient or electrolyte screening, practical recommendations around appropriate malnutrition screening and assessment tools that are useful resources to compliment medical nutrition therapy. It may also include referral pathways to access nutrition services on discharge from hospital and advocacy for the role of the dietitian when engaging with patients with AUD. They may also identify key training and support opportunities for dietitians and identify local champions to support continued professional development. The development of nutrition practice guidelines can act as a catalyst to provide support for resourcing nutrition professionals in AUD populations.

The dietitian can play an extended role in admissions that may have a greater length of stay. In longer-term residential treatment centres, where acute nutritional issues may have been resolved or stabilised, additional consideration may be made to educational programs and establishment of relevant food service guidelines [12]. Food service guidelines may consider menu design, supplementation with specific foods or nutrients and management of patient choice [14]. Educational topics may include current dietary guidelines, relevant nutritional deficiencies, emotional and mindful eating, gut microbiome, body image and disordered eating, role of other substances (e.g., caffeine acting as a stimulant), and provide practical advice on budgeting, shopping and meal preparation [12]. While recommended for longer stay addiction treatment programs, they highlight the complexity of nutritional considerations. This includes the need for continued nutrition intervention on transition from hospital to the community to support nutrition and contribute to improving health and nutrition outcomes.

The integration of a dietitian into local drug and alcohol teams may also contribute to improved health and nutrition outcomes for patients. Collaborative care can bridge many of the gaps commonly experienced by patients with multiple chronic health conditions including those with AUD [15]. Collaborative care also provides opportunities to screen for co-existing problems [15], for example, screening or assessing risk of malnutrition. Patients admitted to hospital for alcohol withdrawal are likely to have co-occurring mental health disorders such as anxiety or depression [16], and suffer from other physical conditions such as hypertension or advanced liver disease [17]. They may also have limited access to appropriate food and fluids and may benefit from the input of other multidisciplinary team members such as social workers and non-government organisations. Other health conditions, disorders or other risk factors could be best identified and addressed through a multidisciplinary approach. There is established evidence that a multidisciplinary approach can improve health outcomes for those with alcohol related liver disease and AUD [18]. Previous research has identified that social and environmental factors may also contribute to a patient's ability to access nutrition-related services [19]. For example, additional appointments may be perceived as a burden to family members who may need to provide transport or may be a barrier if additional costs are associated with the service. While the hospital admission is an opportunistic moment to provide nutrition related advice, patients may often feel overwhelmed and benefit from being provided additional information at additional time points during their treatment [19].

The role of the dietitian and the prescription of nutrition interventions needs to consider the social and environmental context of the patient and their lives. We recently interviewed 31 health-care professionals in an Australian teaching hospital, dietitians were identified to be able to provide specialist nutrition advice. However, dietitian capabilities and the patient context may influence the implementation of nutrition interventions. Guidelines for the inpatient treatment of alcohol withdrawal should provide strategies and recommendations on best supportive care including communication strategies, ensuring adequate nutrition and hydration, creating a calm and supportive environment and symptom monitoring to ensure targeted therapy (e.g., agitation and sedation) [20]. An individualised strengths-based, person-centred approach to care may assist health-care professionals understand behaviours and the care needs of patients admitted to hospital for alcohol withdrawal [21]. This accompanied by motivational interviewing is a patient centred and structured approach to behaviour change [21]. For those pre-contemplative or contemplative, it is important to engage in discussions around harm minimisation and promote ongoing engagement with services including nutrition-related care [21]. Nutrition related harm minimisation strategies may include discussions around alternating alcohol consumption with other fluids, not drinking on an empty stomach and eating food when drinking, re-enforcing the importance of continued thiamine supplementation if the patient is to continue drinking, and providing details or resources relevant to nutrition the patient or their carers may look at in the future.

The specialist skills of dietitians are critical in improving nutrition and health outcomes in patients admitted to hospital for alcohol withdrawal. Future research should consider the integration and evaluation of dietitians in local drug and alcohol teams. Additional consideration should be made to the training and educational needs required to support dietitians working with patients admitted to hospital for alcohol withdrawal. This may be best supported through the development of guidelines relevant to nutritional management while also considering staffing and resourcing requirements.

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