September 15, 2017
Leroy A. Richardson
Information Collection Review Office
Centers for Disease Control and Prevention
1600 Clifton Road NE., MS-D74
Atlanta, Georgia 30329
Re: Drug Overdose Response Investigation (DORI) Data Collections (Docket No. CDC-2017-0055)
Dear Sir or Madam:
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Disease Control and Prevention (CDC) in response to the data collection published in the July 17, 2017 Federal Register regarding the Drug Overdose Response Investigation (DORI) Data Collections (Docket No. CDC-2017-0055).a The Academy is the world's largest organization of food and nutrition professionals, with more than 100,000 members comprised of registered dietitian nutritionists (RDNs), nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists. We are committed to improving the nation's health through food and nutrition and providing medical nutrition therapy (MNT)b and other nutrition counseling services to meet the health needs of all citizens, including those with eating disorders (EDs) or substance use disorders (SUD).
The Academy supports the proposed data collection as necessary for the proper performance of the functions of the agency, particularly given the practical utility resulting from the collections. We respectfully offer recommendations below from Academy member David A. Wiss, MS, RDN, on behalf of our Behavioral Health Nutrition Dietetic Practice Group for potential improvements to the data collections and as support for the claim that nutrition can play a very important role in promoting wellness during the recovery process, thereby helping to reduce relapse and accidental overdose or death.
A. Eating Patterns and Substance Use Disorders
There are several studies that document substandard eating patterns during drug use, including inadequate intake leading to micronutrient deficiencies [1-6] and malnutrition [7-11]. Abnormal preference for sweetened foods and beverages have been documented in alcoholics [12-14] and other SUDs [15, 16] particularly opioids [17-25]. While micronutrient deficiencies and malnutrition are often corrected by abstinence and recovery, dysfunctional eating patterns such as bingeing and night-eating are often exacerbated during sobriety. Early recovery should be considered a critical time to get nutritional support (e.g. dietary counseling) by a qualified professional such as an RDN.
The overlap between SUDs and EDs has received significant attention in the scientific literature [26-41]. Authors have recently begun to suggest that these disorders be treated concurrently rather than separately. In members' personal experience working in both fields, patients will oscillate between treatments and are seldom treated concurrently. While it is true that RDNs are a requirement for ED treatment, there is no present requirement for RDNs in SUD treatment settings. Based on members' experience working with SUD treatment centers, the use of RDNs is rare most likely because nutrition services are not covered by insurance for SUD. We note that the failure to address food and body image issues in SUD treatment is likely contributing to poor outcomes.
It is predictable that individuals entering treatment for SUD will find other substances to abuse, including food [42-45], caffeine [46, 47], and nicotine [46, 47]. While some would argue that it makes sense to allow unlimited access to such substances during early recovery, others believe that the lack of nutrition and health standards are contributing to poor treatment outcomes. Evidence suggests that gastrointestinal health is linked to mental health [48-51] with strong implications for anxiety and depression. Given what is known about the importance of gut health, it seems that improved health and nutrition should be considered a prime intervention for SUD recovery. RDNs in treatment settings are highly qualified to discuss health habits including caffeine and nicotine in the context of nutrition and gastrointestinal health.
B. Nutrition Education and Interventions During Treatment
Several studies have demonstrated links between nutrition education and positive outcomes in SUD treatment settings [52-57]. Some of the studies have suggested that nutrition education has led to reduced rates of relapse, but higher quality research with greater sample sizes are needed to confirm these findings. Given the opioid epidemic and alarming number of overdose and deaths, however, it seems unwise to wait for more data before using nutrition as an intervention strategy.
Nutrition interventions during recovery may promote abstinence and prevent or minimize the onset of chronic illness, improving resource allocation. A review article from the United Kingdom on the role of healthy eating advice as part of drug treatment in prisons concluded that "substance-misuse is a major factor in recidivism and if this could be reduced through improvement of nutritional status, it could be a cost effective means of helping to tackle this problem" . Given the opioid epidemic, public health measures necessitating nutrition standards in treatment settings should be considered critical. There is a timely need for specialized nutrition expertise in SUD treatment centers, and RDNs are highly qualified for the job.
The Academy appreciates the opportunity to offer comments regarding the data collections for the Drug Overdose Response Investigations. We are pleased to offer our assistance and expertise for this and other issues. Please contact either Jeanne Blankenship at 312/899-1730 or by email at firstname.lastname@example.org or Pepin Tuma at 202/775-8277, ext. 6001 or by email at email@example.com with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
Academy of Nutrition and Dietetics
a The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation’s food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
b Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention. [Academy of Nutrition and Dietetics' Definition of Terms list, http://www.eatright.org/scope/, accessed 31 June 2012.] The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.
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