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Nutrition and Diet of Problem Drug and Alcohol Users in Drumchapel, Glasgow April Shaw (SDF Research Officer) and Kenny Macdonald (Drumchapel LIFE Healthy Living Centre) March 2007 Contents page 1. Introduction 2 1.1 Background 3 1.2 Methods 5 1.3 Data Input, analysis and report writing 6 2. Study Findings 7 2.1 Demographics 7 2.2 Drug and Alcohol use 10 2.3 Eating Patterns 12 2.4 Service Response 15 2.5 Food Provision 17 2.6 Health and Quality of Life 18 2.7 Local Health Initiatives 20 2.8 New Projects 21 3. Summary of Main Findings and Recommendations 22 References 27 Appendix 1. Drumchapel LIFE Healthy Living Centre: 28 Nutritional Needs Questionnaire Results 1 Nutrition and Diet of Problem Drug and Alcohol users in Drumchapel, Glasgow 1. Introduction In 2006 the West Glasgow User Involvement Team (WGUIT) 1 and Scottish Drugs Forum [SDF] undertook a consultation exercise to identify the nutritional needs of a sample of problem drug and alcohol users within the Drumchapel area. The need for this study was highlighted by a working group of local officers, based in the Drumchapel, who identified that many drug/alcohol services had very little in their assessment procedures around diet and nutrition, despite the fact that a significant proportion of their client group had clear problems in this area. On behalf of this working group, Drumchapel LIFE Healthy Living Centre surveyed a mixture of 30 local voluntary and statutory social care and health staff, asking questions such as: did staff feel that their services assessment procedures were adequate in identifying the nutritional needs of service users and how helpful would the provision of training on basic nutritional advice be for staff in supporting their client group? (See appendix 1). Following on from this, the working group approached the WGUIT to carry out a study with local service users with a view to influencing or changing aspects of local service provision. The main aim of this consultation exercise was to: • Identify potential service improvements or changes (e.g. inclusion of nutrition related questions in assessment processes) • Identify the broad needs of service users in relation to nutrition and health 1 WGUIT are volunteers consisting of ex/current addiction service users who are recruited, trained and supported by a User Involvement Development Officer [UIDO] to undertake activities that will impact on the planning and delivery of services. 2 • Develop a series of recommendations aimed at addressing the nutritional needs of people with problem drug and alcohol use 1.1. Background A healthy diet is essential for a healthy life and good nutrition from childhood to adulthood enhances not just the length but also the quality of life. The dietary needs of problematic drug and alcohol users are often overlooked or unresolved and this may be due to a number of factors such as poor use of primary health services, social exclusion, unemployment and poverty. Many drug and alcohol users have diseases directly or indirectly resulting from their substance use, such as hepatitis, alcohol liver disease and HIV which makes the need for a healthy diet even more important. It is important that drug and alcohol users can access good advice regarding nutrition and healthy diets and that those with particular physical conditions get specialist dietary support and guidance. 2 Lack of nutritious food or insufficient amounts of food in conjunction with the effects of drugs, alcohol and chronic disease will reduce the body’s ability to absorb and utilise nutrients. Although limited, a number of studies of opiate users entering methadone maintenance treatment have found that many are severely malnourished and that nutrient shortages delay the rate and quality of recovery. 3 Problematic drug and alcoholic users may forget what it feels like to be hungry and interpret the feeling of hunger as a drug craving, for example relapse is likely when blood sugar levels fluctuate due to the irregular intake of food. Various specific deficiencies were observed in studies that looked at clients in methadone maintenance treatment (MMT), including significantly low levels of folic acid, beta-carotene, and several vitamins: C, E, and D. 4 Along with vitamin D shortages, researchers have reported a high occurrence of osteoporosis (thinning 2 Helen Sandwell, Fuel for Recovery in Drink and Drugs News 16.01.06 Hebert JR, Nichols SE Jr, Kabat GC. Indicators of nutritional status among clients from a New York City methadone treatment center. Journal of Substance Abuse Treatment. 1990;7(3):161-165; Szpanowska-Wohn A, et al. Nutritional problems of persons qualified for the methadone treatment. Part I. Nutritional status of opiate addicts [English abstract]. Przegl Lek. 2000;57(10):539-543.cited in http://www.atforum.com/siteroot/pages/current_pastissues/Fall2004.pdf 4 Huggins ND, Khaled MA, Cornwell PE, Alvarez JO. Nutritional status and immune function in cocaine and heroin abusers and in methadone treated subjects. Research Communications in Substance Abuse. 1991; 12(4):209-215. 3 3 bones) in MMT patients, particularly in males. 5 They suggested that these deficiencies might account for many of the bone pain complaints among MMT patients. It is important to note that, in all cases, methadone was not specifically considered to be a cause of the nutritional deficiencies. Rather, life-style factors and poor diets were the more likely sources of problems. Diets of patients entering MMT have been observed to vary widely in terms of calories, but usually include high consumption of items low in protein and high in sugar (e.g., cakes, sweets). 6 These habits appear to continue during treatment and also include high consumption of fats. Sweet foods and those rich in fat have been proposed as artificially stimulating the reward system in the brain, similar to addictive substances. Of further concern, many psychiatric medications (e.g., antidepressants, antipsychotics, and others) used to treat MMT patients with dual disorders can affect food intake and nutritional status. 7 These possible effects must be taken into account when designing a nutrition improvement program. A one-program-fits-all approach could be ineffective or even harmful. In addition to the needs of drug and alcohol users the nutritional intake of significant others who may live in the same household should also be considered; this is particularly important in relation to the needs of children in their care. A recent report showed that 53% of children living in Glasgow had decayed, missing or filled teeth due to poor diet and a high intake of sugar through fizzy drinks. 8 This figure may be higher among the children of problematic drug and alcohol users. Furthermore the Hidden Harm report stated that ‘poor maternal nutrition may have significant longterm consequences for the health of the unborn child.’ A maternal diet that is low in green vegetables may result in folic acid deficiency, increasing the risk of neural tube 5 Dembinski, S. Vitamin D – A Solution for Bone Aches during MMT at http://www.brugerforeningen.dk/bfny.nsf/Pagesuk/A6BADB48F4E80590C12571C50052E21B?OpenD ocument&S=UK 6 Szpanowska-Wohn A, et al. Nutrition disorder in persons qualified for the methadone treatment. Part II. Food choice and intake in diets of opiate addicts [English abstract]. Przegl Lek. 2000;57(10):544-548. cited at http://www.atforum.com/siteroot/pages/current_pastissues/Fall2004.pdf 7 Gray G.E., Gray L.K. Nutritional aspects of psychiatric disorders. Journal of the American Diet Association. 1989; 89(10):1492-1498. 8 Sunday Herald 2.04.06 4 defects in the baby. 9 As noted problem drug and alcohol use is often associated with poor diet which is high in sugar and low in protein, fruit and vegetables therefore it is likely that in many cases pregnant problematic drug and alcohol users will have poor nutritional status. On a practical level, those living in deprived areas where fewer people are car owners or where public transport is poor have most difficulty accessing shops that sell a range of affordable foods to make up a healthy and balanced diet. People may access smaller local shops where processed food is more readily available and there is less opportunity to buy fresh ingredients. Furthermore, individuals may never have learned cooking skills and may have difficulties budgeting for food; still others may live in temporary or unstable accommodation or may not have access to cookers or fridges to store food. The nutritional needs and eating patterns of drug and alcohol users is a relatively unexplored field and this study will aim to add to our knowledge of the diet and nutritional status of a sample of service users within the Drumchapel area. 1.2. Methods The methodology used in this study involved 47 one-to-one structured interviews. The structured questionnaire was developed by WGUIT in partnership with SDF’s research officer. The questionnaire covered the following topics: • Basic demographic information including current drug and alcohol use • Eating patterns • Service responses • Access and barriers to food provision • Health and quality of life questions • Knowledge of local health initiatives All study participants received a £10 voucher for the local “Fruit Barra”, a fresh fruit and vegetable outlet run by Drumchapel LIFE Healthy Living Centre. 9 Advisory Council on the Misuse of Drugs (2004) Hidden Harm Report, Home Office 5 Members of the WGUIT, comprising ex and stable drug users, undertook the interviews. The team received training in research techniques by consultants Human Factors Analysis, and were supported throughout the period of the study by the Drumchapel Substance Use Strategy Coordinator (SDF) and SDF Research Officer. Prior to undertaking fieldwork SDF Research Officer provided a one day training session in interview techniques where the questionnaire was piloted among the WGUIT in order to highlight any irregularities in the questionnaire and make any necessary amendments. Recruitment of the study participants was organised by David Bain (Development Officer, Glasgow City Council West Community Addiction Team). Based on advice from Glasgow NHS Research Ethics Committee ethical approval was not sought for this study as no study participants were recruited from statutory health services or the West Community Addiction Team. Participants were recruited through a snowball technique from the street or at a drop-in facility (The Living Room) and were known to David Bain and/or the interviewers Protocols for rules of conduct at interviews were given to all interviewers at the commencement of work along with procedures on confidentiality. A study information sheet and consent form was provided to each potential interviewee to read and sign prior to the interview and participation in the study was entirely voluntary. In addition to this a number of inclusion/exclusion procedures were employed to maximise the successful conduct of interviews and safeguard the security of interviewers. 1.2.1. Data input, analysis and report writing Data input was carried out by David Robertson, a member of the WGUIT, using SNAP 7 and was checked and verified by SDF Research Officer. Analysis was carried out by SDF Research Officer using SPSS v14 (Statistics package). The report was written by SDF Research Officer in conjunction with Kenny Macdonald, Manager, Drumchapel LIFE Healthy Living Centre. 6 2. Study Findings The following section comprises the findings from 47 interviews with drug and alcohol service users from the Drumchapel area in Glasgow. 2.1 Demographics Gender: The gender distribution of the sample was • Male • Female 74% (n35) 26% (n12) Age: The mean age was 36 years. Ages ranged from 20 to 65. Chart 1 below shows the age bands of study participants. The largest proportion of respondents was aged between 30 and 39 years (43%, n20). Chart 1. Age Bands age band 20 Frequency 15 20 42.55% 10 5 14 29.79% 11 23.4% 2 4.26% 0 20 - 29 years 30 - 39 years 40 - 49 years >60 years age band 7 Household Information The respondents were asked how many people lived in their household (including the respondent). • 34% (n16) lived in single person households • 28% (n13) lived in three person households • 23% (n11) lived in two person households • 11% (n5) lived in four person households • 4% (n2) lived in five and six person households The majority (n29, 62%) lived in rented public sector housing. Six (13%) respondents stayed in supported accommodation, five (11%) lived with parents, five (11%) privately rented and one person owned their house. The respondents were asked for their postcode in order to identify the areas in which they lived. Of the 26 people who answered, the largest proportion of respondents (n19, 73%) lived in decile 1, the most deprived 10% of Data Zones as measured by the Scottish Index of Multiple Deprivation (SIMD). 10 Six people (23%) stayed in deciles 2 and 3 and one person lived in decile 6. Employment status In terms of employment • 72% (n34) were unemployed and had previously worked • 25% (n11) were unemployed and had never worked • One person (65 year old) was retired Of the 25% who were unemployed and never worked, three people were in their twenties, four in their thirties and five were in their forties. Among the five in their forties three reported a long-term illness. 10 Scottish Neighbourhood Statistics, http://www.sns.gov.uk/ 8 Income status All respondents were receiving state benefits. • 51% (n24) received Income Support • 47% (n22) received Incapacity Benefit • 20% (n9) received Disability Living Allowance • 11% (5) received Job Seekers Allowance • 2% (n1) received New Deal • 2% (n1) received Retirement Pension (The figures add up to more than 47 due to some respondents’ receiving multiple welfare benefits.) The majority of respondents (62%, n29) received their benefits on a weekly basis; 34% (n16) received their benefits on a fortnightly basis; and one person received their benefit monthly. One response was missing. The mean sum of benefit received was £104.25p. The minimum received was £33 (job seekers allowance) and the maximum was £300 (retirement pension). Over half the sample (64%) reportedly received £100 or less per week. Chart 2 shows the income bands for 44 respondents. 9 income bands 12.5 Frequency 10.0 7.5 13.0 29.55% 10.0 22.73% 5.0 7.0 15.91% 7.0 15.91% 2.5 1.0 2.27% 4.0 9.09% 2.0 4.55% 0.0 <£50 £51 - £75 £76 - £100 £101 - £125 £126 - £150 £176 - £200 £251 - £300 income bands The incomes reported by the respondents are individual incomes and not household incomes so may not reflect the total sum of income in a household (e.g. other household members’ income or benefits, council tax and housing benefits). 2.2 Drug and Alcohol Use The following section is an analysis reported drug and alcohol use of the respondents. Prescribed Drug Use Thirty seven (79%) respondents were currently prescribed drugs. Of these 26 (70%) were prescribed methadone. Illicit Drug Use Twenty-one respondents (47%) reported using illicit drugs. Of the respondents using illicit drugs 10 • 40% (n12) were using cannabis. • 40% (n8) were using street bought diazepam • 25% (n5) were using heroin • 20% (n4) were using cocaine or crack cocaine • 15% (n3) were using street bought methadone The main drug of choice among the 21 respondents was: • Cannabis (32%, n7) • Heroin (23%, n5) • Methadone (street bought)(14%, n3) • Amphetamines/Speed (9%, n2) • Diazepam (9%, n2) • Dihydrocodeine (5%, n1) • Crack cocaine (5%, n1) The 21 respondents using drugs used them on a regular basis; 16 respondents use on a daily basis; 2 respondents used 2 - 3 times weekly; one person used monthly; two people declined to answer. Among the four respondents who used heroin on a daily basis the reported average daily spend for their drug use is £70 (daily spend ranged from £50 - £90). Alcohol Use Almost half the sample (n22) reported drinking a variety of alcoholic beverages. Seven people drank on a daily basis. Recorded levels of drinking among the seven daily drinkers ranged from six cans of lager daily to six litres of cider daily. One respondent with Hepatitis C reported drinking two litres of wine on a daily basis. The average daily spend on alcohol was £12 (daily spend ranged from £7 to £20). 11 The levels of daily drinking far exceeded the recommended daily amount of three to four units for men and two to three units for women. 11 2.3. Eating Patterns The respondents were asked about their eating patterns in order to ascertain how regularly they ate and types of food eaten. • 21% (n10) reported eating three meals per day (breakfast, lunch, dinner) • 25% (n12) reported eating two meals per day (lunch and dinner or breakfast and dinner) • 11% (n5) reported eating one meal per day • 38% (n18) reported irregular eating patterns Despite almost half the sample reporting eating two to three meals per day, it is of concern that 11% reportedly eat one meal per day while over one third report irregular eating patterns. Furthermore when asked ‘Do you have days where you don’t eat at all’ over half the sample (n27, 57%) reported having days where they ate nothing at all. Nine people (19%) reported they may go up to three days without eating at all. Asked why they might not eat at all in a day; seven people stated it was due to drinking, nine reported it was due to their drug use, four said they could not be bothered. Among the nine who may miss meals for up to three days; four are prescribed methadone, three use heroin daily, one uses speed and one ‘drink binges’. 11 http://www.alcohol-focus-scotland.org.uk/aboutalcohol/units.asp 12 Average time first eat • before 10 am 43% (n20) • 11am - 12 pm 15% (n7) • 12pm - 2pm 13% (n6) • 3pm - 6pm 4% (n2) First thing consumed Asked what was the first type of food consumed during the day: • Eight people reported eating cereal • Four reported eating toast • Four people ate rolls and meat • Three people ate fruit • Four people reported consuming alcohol first Other consumables included tea, coffee, cigarettes, irn bru, painkillers and milk. Medication before eating Twelve people reported having to take medication before eating. The reasons for this were largely that they had been advised that their medication could not be taken on an empty stomach. Fresh Fruit and Vegetables The majority of respondents (83%, n39) stated that they ate fresh fruit and vegetables; eight (17%) respondents stated they did not eat any fresh fruit or vegetables. Portions The respondents were shown visual information cards supplied by the Drumchapel LIFE Healthy Living Centre with the recommended five daily portions of fresh fruit and vegetables. • Eighteen people stated they ate one to two portions of the recommended daily amount on a daily basis • Nine people said they ate three of the recommended daily portions on a daily basis 13 • Three people said they ate the recommended five portions on a daily basis. Initially then, there is a high proportion of respondents reporting eating fresh fruit and vegetables (83%) but when asked about their daily consumption less than a third (31%) eat three or more portions of the recommended daily amount. Cooked Meals Asked how often they cooked a meal: • 24 said daily • 8 said someone else cooked for them (usually a relative) • 11 people said they ‘never’ cooked 15% of the sample reported cooking a meal with ‘fresh ingredients’ daily (as opposed to processed food) whilst a further 25% said they used fresh ingredients at least once or twice a week. However it is not vital that fresh ingredients be used in preparing and cooking meals on a daily basis as processed food can be as nutritious and safe to eat as fresh produce. Transportation and poor storage can lead to fresh food losing nutrients whereas frozen or canned vegetables can retain their nutrients. Moreover fresh ingredients are often more expensive to buy than processed food therefore it is important that people with substance use problems are provided with information and skills that enables them to appreciate the importance of a balanced diet . Of the 16 respondents who live in single-person households • six said they never cooked meals (though three people said their meals were cooked by a relative) • five cook a meal daily • five cook at meal two to four times per week Fast food 14 The respondents were asked ‘On average how many takeaways or fast food meals do you eat in a week?’ • Eighteen (38%) people reported eating one or two fast food meals per week • Thirteen (28%) people reported never eating fast food meals • Six (13%) people reported eating three to four fast food meals per week • Three (6%) people reported eating seven fast food meals per week Typical fast food/takeaway meals included food from local chip shops, Chinese food, Indian food and kebabs. Changes in eating patterns and weight Forty three people said their eating patterns changed while they were using drugs/alcohol. The main change was loss of appetite. Asked if their weight changed while they were using drugs/alcohol forty people said it did. The majority reported losing weight whilst five people said they gained weight. 2.4. Service Response The research team felt it was important to explore whether services were asking clients about their weight and diet and if so whether they were offered any advice and/or information. Weight At the time of interview 24 (51%) respondents were concerned about their weight. The main concerns were: • Underweight (n11) • Overweight (n7) Sixteen (34%) people said they had been asked about their weight. Of these six people stated their addiction counsellor had asked about their weight; nine people said their doctor had asked (one response missing) 15 Diet Thirteen people (28%) reported having been asked about their diet. Four people had been asked by their doctor; seven people had been asked by their counsellor workers at Momentum and Star Partnership were cited by three people. Advice Thirteen people (28%) had been offered advice by their doctor, counsellor or nursing staff at clinics. Eleven people said the advice was very or quite useful; two people said the advice they were given was ‘not useful at all’. A nutritional needs questionnaire was circulated by Drumchapel LIFE Healthy Living Centre to substance misuse workers within the Drumchapel area. Thirty responses were collected and the findings suggest that the majority of workers who replied considered the existing initial assessment of clients provided ‘little understanding’ of their clients overall nutritional needs. The majority of responses said training on basic nutritional advice to clients would be helpful (see appendix 1). Nutritional supplements Twenty eight people had either been offered or had bought nutritional supplements. The nutritional supplements offered or bought were: • Vitamins • Cod liver oil • Omega 3 • Complan • Iron tablets • Garlic capsules Asked if the supplements made a difference to their health, 20 people responded positively. They said • Felt better • Put weight on • Improved memory 16 • Improved appetite • More energy Meal supplements Twelve people had been offered meal supplements such as Fortisip and Ensure. Seven people said the supplements made a difference to their health in that they felt healthier, had more energy and felt more mentally positive. No -one had sold on the nutritional or meal supplements offered to them. 2.5. Food Provision Asked how much their household spent on food on average per week the majority 67% (n30) reported spending less than £40 per week on food; 31% (n14) below £20. Six people reported spending between £60 and £100 (see Table 2 below). Table 2: Household food spend per week Food Frequency Valid Percent < £20 14 31.1 £21 - £40 16 35.6 £41 - £60 9 20.0 £61 - £80 3 6.7 £81 - £100 3 6.7 Total 45* 100.0 spend *Two responses missing These figures should however be viewed with some caution as seven respondents reporting a food spend of less than £20 per week were living in households of two to four people. The majority of respondents bought their food from the main local supermarket chains such as: 17 • Farmfoods (n21) • Somerfield (18) • Asda (n13) • Morrisons (n6) Farmfoods and Somerfield are in Drumchapel while Asda and Morrisons are in Clydebank and Anniesland respectively. No-one reported buying from Sainsbury’s which is in Drumchapel but this could be due to the higher cost of food from this particular outlet. Only three people mentioned buying directly from a butcher, fruit shop or grocery van. The main reasons people chose to shop at the local supermarkets was: • Convenience • Cheaper • Quality • Variety Travel time to the shops took no longer than 35 minutes and the majority (57%) travelled no longer than 20 minutes. Kitchen equipment The majority had a working fridge (98%); working cooker (94%); and a working microwave oven (79%). 2.6. Health and Quality of Life The respondents were asked about their health, specifically whether they had any long-term illnesses and problems with digestion. 18 Long Term Illness Thirty three (70%) respondents reported having a long-term illness. The two most frequent illnesses reported were: • Depression 39% (n13) • Hepatitis C 27% (n9) Four of the respondents diagnosed with Hepatitis C had been offered advice on their diet and nutrition by a worker or GP whilst five reported that they had not. Of the nine people diagnosed with Hepatitis C only two reported drinking – one on a daily basis and one ‘depending on mental state.’ It is important that individuals with HCV status try to maintain a balanced diet as maintaining or providing healthy eating patterns may potentially slow the progression of HCV infection. An Australian study of HCV infected participants showed that poor diet, junk food, fatty and sugary foods could trigger symptoms such as fatigue, nausea, abdominal discomfort and arthralgia (joint pain). However the dietary factors that could relieve these symptoms included consuming less fat and carbohydrates and increasing intake of water. 12 At present the UK Hepatitis Resource Centre is participating in a research study on Literacy and Readability in Relation to Hepatitis C Information Media. Initial findings suggest that drug users prefer verbal information to written information; it is therefore important that drug and alcohol workers are provided with information and training in order to relay this to their client groups. 13 Digestion Fifteen (32%) respondents stated they had digestion problems. The most frequent problem was constipation (n10) and heartburn (n3). The average length of time respondents reported having digestion problems was eight years but these problems ranged from one year to ‘over 20 years.’ 12 Carolyn Lang, “Discovery of symptom clusters gives insight into the Hep C experience” The Hep C Review, Edition 55, December 2006 13 Professor Avril Taylor - speech at SDF Hepatitis C Conference (28.02.07) 19 Four of the respondents reporting digestion problems had been offered advice on their diet and nutrition; ten said they had not and one respondent did not know if they had been offered advice. The receipt of advice among those respondents reporting problems with digestion is very low however we did not ascertain whether the respondents had actually asked for advice. 2.7. Local Health Initiatives The WGUIT wanted to explore people’s awareness of Drumchapel LIFE Healthy Living Centre which has been operating for four and half years and operates a ‘fruit barra’ selling fresh fruit and vegetables at Stonedyke neighbourhood centre and some smaller local outlets attached to organisations or projects (e.g. Momentum). The respondents were asked if they were aware of any local food cooperatives. Nine people said they were aware of the Stonedyke ‘fruit barra’ and one person mentioned the Co-Operative shop on Alderman Road. Asked if they knew of any healthy living initiatives in the area, six people said they did. They mentioned • Drumchapel Forum • Drumchapel Initiative • Drumchapel LIFE Healthy Living Centre • COPE • WGUIT Awareness of local food cooperatives and health initiatives is limited therefore it would be advisable to disseminate information of said local projects to drug and alcohol workers and organisations as well as the wider community. Leisure Facilities Sixteen people said they rarely or never exercised. Thirty-one respondents said they did exercise although the frequency varied from daily to once a week. 20 Eighteen people said they used local leisure facilities for exercise. Again the frequency varied from daily to once a week. Motivation Just over half the sample (53%, n25) said they were motivated to change their diet. Measures that would help people change their diet were cited as: • Changes in lifestyle (stop drinking/drug taking) (n9) • Increased income (n8) • information on diet and cookery courses (n8) • Access to healthier/cheaper foods (n3) • Increase exercise (n3) • Personal plans/food diaries (n2) Barriers that prevented respondents from changing their diet were: • No barriers (n17) • Income (n12) • Substance use (n5) • Motivation/’Laziness’ (n5) Information Fifteen people thought there was enough diet and nutrition information available to the public although the majority (57%, n28) thought there was not. 2.8. New Projects Thirty nine respondents said they would consider changing their diet after taking part in the survey and 32 said that if any diet and nutrition projects were set up locally they would be interested in receiving information on them. Seventeen people said they would need help with travel costs and four people said help with child care would be required. The contact details for interested parties were given to the Development Worker at GCC West Community Addiction Team. 21 3. Summary of Main Findings and Recommendations This is a summary of the main findings from a consultation exercise to identify the broad needs of drug and alcohol service users in relation to their diet and nutrition in the Drumchapel area. Each of the main findings is followed by recommendations. The need for the study was highlighted by a working group of local drug and alcohol officers who identified that drug and alcohol services have little in their assessment procedures pertaining to diet and nutrition. Interviews were conducted by the West Glasgow User Involvement Team with 47 drug and alcohol users. 3.1 Finding Almost half the sample (49%) reported irregular eating patterns and over half the sample reported days where they ate nothing at all. Eleven per cent of the sample ate only one meal per day. Data from the Drumchapel LIFE Healthy Living Centre survey (see appendix 1) revealed that all the workers who responded (n30) stated they were aware of clients experiencing difficulties eating a balanced diet as a result of their drug and alcohol use. Furthermore 24/30 workers said the initial assessment of clients provided ‘little or no understanding’ of clients’ nutritional needs. Recommendation Review existing processes of assessment to identify clients’ nutritional or dietary needs. This would enable workers’ clients’ nutritional or dietary needs to be identified at an early stage of contact and followed up when stabilised. 3.2 Finding Half the sample cooked a meal on a daily basis, while only one third of people living in single-person households reported doing so. The majority of the sample reported eating fresh fruit and vegetables although only three people reported eating the recommended five portions on a daily basis. Spending on food appeared to be relatively low but these figures should be viewed with caution. However given that the total sample was on benefits it can be reasonably assumed that a high proportion of their income is spent on food. 22 Recommendation There is a need to develop accessible information for clients that is linked to existing support services. Information should combine basic balanced dietary information with practical skills such as cookery classes and food budgeting skills. One possible venue is the new community centre on Kinfauns Drive which has a special training kitchen so the facilities exist for cooking skill programs that could be developed in partnership with the centre. 3.3 Finding Half the sample was concerned about their weight. The report identified that just over a quarter to a third of the sample had been asked about their weight and diet by a number of different professionals (e.g. doctor/counsellor) and where advice had been received this was viewed positively. In addition findings from the Drumchapel LIFE Healthy Living Centre survey suggested that the majority (22/30) would find the provision of training on ‘giving basic nutritional advice to clients’ helpful. Recommendation Improve joined up working across organisations and sectors in relation to diet and nutrition. Furthermore in light of the findings from the Drumchapel LIFE Healthy Living Centre survey of local voluntary and statutory social care workers there is a need to provide awareness raising and training on diet and nutrition to professionals working with drug and alcohol users. 3.4 Finding Among the sample interviewed all bar one were currently unemployed and receiving benefits. Recommendation With an increasing emphasis on enabling people to return to work through employability and training programmes it would appear that this is one particular support sector that would benefit from increasing awareness of balanced dietary and nutritional information in order to maximise clients’ ability to sustain employment or training. 23 3.5 Finding Nutritional and meal supplements had been used by a large proportion of the sample and the majority said these had made a positive improvement to their health. Recommendation Information and supply of nutritional and meal supplements could be beneficial although it should be highlighted that these are a supplement to, and not a substitute for, meals. 3.6 Finding Almost three quarters (70%) of the sample reported long-term illnesses (39% depression: 27% Hepatitis C). Over half the respondents with Hepatitis had not been offered advice on their diet and nutrition by a worker or GP. A third of the sample reported digestive problems but few had been offered advice on their diet. Recommendation Identifying such problems at an early stage in the assessment process would enable workers to follow up on these once clients are stable. Care plans drawn up following assessment should explore clients’ eating patterns and where needed identify and develop include appropriate balanced dietary/nutritional support. In addition it is important that individuals with HCV status try to maintain a balanced diet as maintaining or providing healthy eating patterns may potentially slow the progression of HCV infection. Therefore drug and alcohol workers should be provided with information and training on diet and nutrition for this particular client group while information on healthy living initiatives and support groups such as C Level could be provided and disseminated to drug and alcohol organisations and workers that would enable staff to signpost clients to appropriate local supports and resources. 3.7 Finding Although a number of people were aware of local health initiatives there is a clear need to build on local knowledge and awareness of such among clients and workers. 24 Recommendation Information on healthy living initiatives should be provided and disseminated to drug and alcohol organisations and workers that would enable staff to signpost clients to appropriate local supports and resources 3.8 Finding Over half the sample reported engaging in some form of exercise at least once a week with 18 using local leisure facilities. More importantly over half the sample said they were motivated to change their diet. Recommendation Examine possibilities of organising and expanding on current provision in the area. For example the ‘Relaunch’ project funded by Drumchapel LIFE Healthy Living provides a comprehensive exerciser programme and delivers diet and nutritional workshops combined with practical skills such as cookery classes and budgeting. 25 References Advisory Council on the Misuse of Drugs (2004), Hidden Harm Report, Home Office Gray GE, Gray LK. (1989) Nutritional aspects of psychiatric disorders. Journal American Diet Association, 89(10):1492-1498. Hebert JR, Nichols SE Jr, Kabat GC. (1990) Indicators of nutritional status among clients from a New York City methadone treatment center. Journal of Substance Abuse Treatment. 7(3):161-165 Huggins ND, Khaled MA, Cornwell PE, Alvarez JO. (1991) Nutritional status and immune function in cocaine and heroin abusers and in methadone treated subjects. Research Communications in Substance Abuse.12 (4):209-215. Lang, Carolyn (December 2006) “Discovery of symptom clusters gives insight into the Hep C experience” The Hep C Review, Edition 55 Sandwell, Helen, (16.01.06) Fuel for Recovery, Drink and Drugs News Web Sites Scottish Neighbourhood Statistics, http://www.sns.gov.uk/ Alcohol Focus Scotland, http://www.alcohol-focus-scotland.org.uk/aboutalcohol/units.asp Danish Drug Users Union, http://www.brugerforeningen.dk/bfny.nsf/Pagesuk/A6BADB48F4E80590C12571C50052E21B?OpenD ocument&S=UK Addiction Treatment Forum: Quarterly Newsletter for Clinical Health Professionals on Addiction Treatment, http://www.atforum.com/siteroot/pages/current_pastissues/Fall2004.pdf 26 Appendix 1 Drumchapel LIFE Healthy Living Centre Nutritional Needs Questionnaire Results Number of Questionnaires returned: 30 Are you aware of clients you work with who experience difficulties eating a balanced diet as a result of their problem use of alcohol or drugs? Yes: 30. No: 0. Main issues for these individuals? All of the above, as per issues suggested on questionnaire: 27 Additional Issues: Ready Meals/ ‘Quick fix’ foods/ Low priority for spending limited income/ Eating Disorders/ No cooking facilities/ Craving for sweet things/ Lack of knowledge on eating and health/ No incentive to cook for one/ Health issues which prevent people eating/ Poor knowledge of essential nutrients e.g. Vitamins and Minerals/ Chaotic drug and alcohol use/ How much does your existing initial assessment of clients provide you with a good level of understanding of their overall nutritional needs? Not at all: 7 Only a little: 17 Adequately: 4 A lot: 2 How helpful would you find the provision of training on giving basic nutritional advice to clients? Not at all: 1 Only a little: 7 A lot: 22 27 Barriers to developing action to address the nutritional needs of this group: Money spent on alcohol/ drugs Can only give people advice when/ once stable Realistic baseline of diet and effect on health Clients with low self esteem may have not eating as a means of control People in crisis Financial issues Not reaching all ‘groups’ if the are not using services. May not see services for them or meeting their needs Cooking advice and skills low Priority for funding addiction Funding for staff training People putting the ideas into practice may be a problem Preconception of effort needed for ‘healthy’ eating Lack of trained staff to sustain concentrated support Lack of commitment from client group Poor access to facilities e.g. Kitchens Clients are unaware how their diet is affecting their health Ideas to overcome these barriers: Food packs- hot soup to take to visits Education re importance of diet alongside other aspects of recovery Community based classes with practical learning and budgeting Promotion of healthy eating education Need for a different strategy for different groups as one size will not fit all Use of the Living Room e.g. as a venue for use by street drinkers, fresh fruit at STAR and West CAT Cooking skills training for eating on limited budget Nutritional assessments and healthy eating plans in assessment/care plan Clients keeping nutritional diaries which could be discussed/reviewed Healthy food at service locations Funding for work to support long term lifestyle change Staff who can work with clients to show them what to do in their own homes Financial support for healthy eating Additional support in ‘real’ environments Food co-op scheme Free fruit and veg Free tasters of inexpensive alternative foods Clients getting involved in growing, producing and promoting healthy foods Drop In healthy eating community café Information, Information, Information! Good promotion Highlighting the issues so all agencies can work together to tackle them Informal sessions on nutrition perhaps on a drop in basis Try to disseminate info through peer groups Help with budgeting skills Staff training Different programmes which are tailored to stage clients are at Meals/Menu Planning for clients Healthy eating plan for each individual Clients having one to one coaching Information in leaflet form at initial assessment Education, Education, Education! 28