Recovery hinges on lifestyle choices

Pamela M. Peeke, MD, MPH, is waging a fight against an insidious threat in addiction treatment centers, one that has nothing to do with staff burnout or dangerous patient perceptions about an illegal drug. The enemies that Peeke is trying to expose are alien-sounding “hyper-palatables,” the sugary, fatty or salty foods that can trigger compulsive consumption in individuals—and, frequently, cross-addiction in those in early recovery from alcohol or drug dependence.

Peeke is trying to convince often-reluctant patients and the professionals who treat them that a healthy lifestyle (characterized by her three M's of “mind,” “mouth” and “muscle”) is more than a nice accompaniment to sobriety—it is an essential component of lasting recovery.

“You get the eye roll from people, the 'I'll get to it at some point,'” says Peeke, whose 2012 New York Times bestseller The Hunger Fix summarized the latest research on overeating and addiction and offered a three-point plan of attack. “The new science says that if you ever want to achieve a sustained lifelong recovery, you will have to do this within the framework of a recovery lifestyle.”

Peeke will deliver a plenary session titled “Off the Drugs...Onto the Cupcakes: The New Science of Food Addiction” Aug. 2 at the National Conference on Addiction Disorders (NCAD) in St. Louis, presented by the publishers of Addiction Professional.

Facility chain buys in

Elements Behavioral Health's CEO, David Sack, MD, read Peeke's book and had colleagues of his reach out to her (both he and Peeke had worked at the National Institutes of Health at separate intervals). He would ask Peeke to visit Elements' facilities. She ran groups with patients and worked to change the culture. Lucida Treatment Center in Palm Beach County, Fla., and Malibu Vista in California have used Peeke's template to adopt a healthy lifestyle approach, and Peeke now serves as senior science adviser to Elements.

Adoption does not always come easy. As Kuala Bless, a licensed dietician at Lucida, describes it, “Without a doubt there's resistance. Some patients like to call us the sugar Nazis.”

Individuals entering treatment tend to be malnourished, and in the few days after detox are not feeling up to par and feel even worse about being deprived of some of the foods they are used to consuming. Peeke's recovery plan is designed to reclaim the brain's reward system from hijacking by hyper-palatables. At Lucida, which maintains a culinary staff of five and two dieticians, patients receive three meals a day made virtually entirely from scratch.

There are some basic principles governing the dietary plan at the center: Natural sweeteners such as honey and maple syrup are used instead of sugar, and the staff stays away from fat-free and sugar-free products. On the other hand, they seek not to communicate an extreme message characterized by talk of “good” and “bad” foods, emphasizing instead a healthy balance. Patients with strong cravings for sweets might receive a small serving of chocolate, for instance. Still, there are those notoriously unhealthy processed foods that Peeke and her followers derisively label as “science fair projects.”

Bless adds, “A patient will ask, 'Why can't I have white bread?'” The answer is, 'You can, but it won't fill you up.'”

Patients, who stay at Lucida for 30 days or more, participate in a weekly cooking group, where they may learn to enjoy the benefits of kale for the first time by mixing it into a healthy smoothie. Staff members also will accompany patients to grocery shopping trips and explain the importance of focusing one's purchases along the store's perimeter. The facility holds a women's “mood group” that explores the connection between food choices and mood, educating patients about how some foods can improve memory and symptoms of depression.

The facility has gone through an evolutionary process in implementing the program. At first, it was allowing residents of the six individual apartments on the property to choose some of their own foods, but Bless says this “was getting out of control.” Now each building is supplied with some of the same food basics. “We're not going to the grocery store every day,” Bless says.

She says staff members see a pronounced change in patients once they have been in the recovery plan for some time. “You notice that their coloring is different; they came into treatment grayish and pale,” Bless says. “They're not as fidgety in group. They're also not as tired in group, because we also emphasize good sleep.”

Peeke began her work at Lucida in 2013 even before the facility opened. “When I did the training at Lucida before every level of staff, they all said to me, 'What about us?'” Peeke says. “Who better to sell this to patients than those who are living it?” Consistency of message has been an important element of success, but of course that doesn't mean a patient still won't find candy stashed in a group room from time to time.

Not a policing approach

Peeke tries in her presentations not to emphasize words such as “diet” and “exercise” (the latter becomes “physical activity,” at first just stressing basic movement). “Once you use the word 'recovery,' people's ears perk up,” she says. “They see the return on investment.”

The idea is to present attractive alternatives, not to act as a diet and exercise police, Peeke says. “I'm one of those people who does what I call 'stealth health,'” she says. “I don't carry a huge neon sign.” Armed with sound information about their options and how they can affect their overall well-being, patients eventually will begin to see the benefits of replacing soft drinks with fruit-flavored water, or reaching for a homemade beet carob muffin instead of a packaged snack cake.

Peeke, an assistant professor of medicine at the University of Maryland and a Pew Foundation scholar in nutrition and metabolism, has been focusing on a different “e” word in recent years: epigenetics, or the effect of environmental cues on individuals' gene expression. “We now understand how each gene comes with a sort of dimmer switch,” she says. “For the athletic gene, we want it on all the way. For the addiction or depression gene, we want to damper that.”

In relation to diet, research has found that diets high in carbohydrates tend to over-activate genes involved in processes such as metabolic inflammation, which is linked to many chronic diseases. The plan laid out in The Hunger Fix (the book is subtitled “The Three-Stage Detox and Recovery Plan for Overeating and Food Addiction”) strives for equal proportions of carbohydrates, protein and fat.

Peeke says she is gradually seeing more openness to a healthy lifestyle model of care within addiction treatment. “The old-school thinking about patients was, 'As long as they're not robbing a bank or stealing from their mother, who cares?'” she says. “Places were putting out hyper-palatables, and often the patients were eating everything that wasn't tacked down.”

Still, she communicates even to those who are receptive to these principles that promoting a healthy lifestyle should never be seen as an ancillary service. “We're looking at establishing a recovery-centric lifestyle,” she says. “It is integral to a successful and sustained recovery that the individual incorporate into the entire recovery process an appropriate recovery food plan, a recovery physical activity plan, and a recovery mental plan.”