Keywords

Introduction

The role of nutrition supporting mental health is a growing field of research. Across mental health populations nutrition concerns may manifest as a side effects of antipsychotic medications (e.g. weight gain and poor cardiometabolic health), disordered eating behaviours (e.g. food restriction, binge eating) or general poor diet quality contributing to mental health symptoms (Barton et al., 2020; Bretler et al., 2019; Firth et al., 2019; Jacka et al., 2017). The Walker Unit must address these concerns while at the same time maintaining adequate nutrition to support normal adolescent growth and development.

Complex Eating Behaviours

A key issue for staff at the Walker Unit is managing the balance between vastly different nutrition concerns and presentations. For example managing meal times and nutrition plans for consumers who are under nourished and those who are over nourished. Consumers who are undernourished may be required to have additional and more desirable snacks and meals than those who are over nourished and aiming to limit these food options for overall health improvements. While individually these management plans are straightforward, in the group dining room setting at meal times, this can lead to challenging behaviour for nursing staff to manage. For example, other consumers may see a lack of equality between food provided to them versus other consumers. Successful techniques staff have found to help manage this include having strong consistent messages amongst staff supervising meals, reinforcing that all consumer have different goals and plans, use of high energy nutritional supplement drinks for consumers experiencing under nutrition to add to the diet rather than copious amounts of discretionary foods which may trigger dietary comparisons amongst patients.

As consumers progress through the Walker programme, and increased time is spent at home and or school, the young person’s nutrition plan must be adapted to suit the change in environment. At this point, the routine and control of the Walker meal structure is altered. Sometimes there is a recurrence of previous abnormal eating, for example binge eating in the context of uncontrolled food availability. At this stage, it is important to liaise with the family network to ensure meal times and portions are kept consistent with the Walker programme to help ensure an easier transition. This is also a prime opportunity for introducing new foods and food environments which may present challenges. During this transition, it is common for eating habits to regress slightly as the consumer manages the many emotions and challenges experienced with the transition.

Creative Angles for Nutrition Management

Early in the evolution of the Walker programme a position of ‘Living Skills Cook’ was created to enable young people to receive freshly cooked meals tailored to their needs. A chef with excellent people skills is employed on weekdays to prepare morning tea, lunch, afternoon tea and dinner. Nursing staff provide breakfast and supper. This model aims to replicate home-style cooking which young people are familiar with and helps to reduce the feeling of institutionalisation (Hartwell et al., 2013). Young people attend meals in a communal dining area and eat with staff. This model allows for choice of meals at the point of service which has been shown to enhance consumer meal satisfaction and in turn assist with achieving nutritional adequacy (Mahoney et al., 2009). On weekends, the unit’s meals are supplied by the hospital’s centralised kitchen. Monotony is relieved by a Saturday breakfast group, run by the occupational therapist, the opportunity for food to be sent in by families, and occasional take-away meals.

The chef receives guidance from the Food Service dietician to ensure meals prepared meet the nutritional requirements for adolescents and are appropriate for this group. This is of particular importance given most young people at the Walker Unit have longer admissions and are predominantly reliant on the hospital provided meals to meet their nutritional requirements. The chef liaises with the staff and young people to ensure the menu is tailored to meet their needs and preferences. The dietician also works closely with the chef to ensure young people with special nutritional needs are well managed. For example, young people requiring a meal plan will have this meal plan organised with the chef to ensure appropriate meal variety and options are available.

The nutrition guide for the Walker Unit aims to provide adequate variety and quantity of all core food groups for adolescents as per the Australian Guide to Healthy Eating for Children and teenagers (Australian Government Department of Health, 2015). Of particular focus for the Walker Unit is vegetarian diets. Often vegetarian diets are requested for ethical and cultural reasons, though at times, they are requested by consumers aiming to restrict their caloric intake. The nutrition guideline developed for the Walker Unit ensures that the protein requirements and iron requirements are met for those requesting vegetarian meals, which often requires education and up skilling with the chef. The chef is then able to creatively implement this to help reduce menu fatigue.

Cooking interventions have been frequently used by occupational therapists in a wide range of clinical settings, with the aims to provide consumers with opportunities for developing life skills, their identity and social relationships among the peers (Farmer et al., 2018). Some young people admitted to the unit have never cooked a meal. Others, owing to circumstances, have had limited opportunity to learn how to cook (Utter et al., 2016).

Cooking groups are used at the Walker Unit to provide the young people with cooking experiences. Each week, the young people would be supported to have a group discussion and make a choice of the recipes for the cooking groups. This provides an opportunity for the young people to try new food or select a culture specific cuisine. Young people are also encouraged to bring in recipes from home for the cooking groups. Young people will be supported to work together during the cooking task, practice social and negotiation skills, learn how to prepare simple meals from basic ingredients. Cooking interventions improve eating behaviour, self-esteem, confidence, concentration, coordination, and provide a sense of achievement (Farmer et al., 2018) (Fig. 15.1).

Fig. 15.1
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Example cooking group set up

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While diet quality is an important consideration for consumers at the Walker Unit, promoting and demonstrating a healthy meal environment is of equal importance. Young people often have not had a positive meal environment for some time prior to their admission to the Walker Unit, and are unaware what constitutes acceptable and normal mealtime behaviour. At the Walker Unit, young people consume all meals in a central dining room area which helps create a family meal sharing experience. Staff also sit at the dining table and consume the same meal provided, again, to encourage a normalised meal experience. During this time, distractions such as phones and television are restricted. The practice of communal meals has also been shown to have positive nutritional outcomes including improved motivation to consume meals, increased meal satisfaction as well as non-nutritional improvements including enhanced socialisation skills (Hartwell et al., 2013).

Staff from all disciplines eat meals with the young people. Doing so affords the opportunity to model normal eating behaviours such as consuming appropriate quantities, embracing a variety of foods, and engaging in socially appropriate conversations while dining. It also affords the opportunity for staff to provide meal support for consumers when needed. For example, young people who are struggling to eat may require regular prompting to consume an adequate amount. Nursing staff also keep food charts and records for consumers if the dietician requests, to help identify meal patterns and if dietary intake is adequate. Finally, sharing a meal is an excellent way for staff to build rapport with the young people.

Overeating and undereating are common challenges. This was previously managed with individualised meal plans for each young person to help them consume an adequate intake. After consultation with the ward chef, this process was found to be confusing for staff around adequate portions to be served at main meals. To help address this the ward chef and dietician developed three pictorial meal plans utilising food and utensils commonly used on the ward to demonstrate consistent portions for young people who need to increase or decrease their intake. See example below (Fig. 15.2).

Fig. 15.2
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Example pictorial meal guide for Walker consumers

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The following case example illustrates a collaborative, non-coercive approach to the management of undereating:

A 16 year old female transitioning to male was referred to the Walker Unit dietician on admission with a request for a vegan diet. The young person had a low body weight, minimal dietary intake, and was severely malnourished. Amongst other concerns there was a risk for refeeding syndrome. The young person was not agreeable, at this stage, to any food offered and was refusing engagement with most aspects of the ward programme. Initial interventions were focused on managing the young person’s risk of refeeding syndrome and increasing their dietary intake. As rapport was established with selected team members, the young person became more agreeable to engaging in dietary interventions. This included initially consuming familiar food provided by family, and familiar hospital food consumed during a previous hospitalisation. Nursing staff maintained food and weight charts. Staff consistently offered and encouraged dietary intake at regular meal times to help encourage the young person increase their intake. In addition to this the young person was prescribed high energy high protein nutritional supplementation to further increase their nutritional intake. After several weeks of this consistent approach the young person started to initiate consumption of meals independently and increased their dietary intake at all meals. The young person became more amenable to trying unfamiliar meals prepared by the ward chef. The young person met with the ward chef and a nursing staff member to discuss meal preferences which further helped to enhance engagement in dietary intake. The young person experienced body image concerns related to their mental health and gender dysphoria which had an impact on their eating habits throughout the earlier part of their admission and coincided with some relapses in dietary intake. With consistent support from staff and open communication with the family and consumer with regards to appropriate food from home, the young person was able to establish a healthy dietary intake. As the consumer became more settled into the ward they started actively engaging in regular cooking groups and individual cooking sessions with the occupational therapist. This included baking a birthday cake for a family member for weekend leave. Prior to leaving the Walker Unit the young person was able to achieve and maintain a healthy weight with dietary intake alone (no nutritional supplementation).