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Are you asking depressed patients about their diet? He says you should do a new study. A comprehensive approach to treating mental health conditions should include a personal plan to address nutritional deficiencies, improve gut microbiota, and change dietary habits to achieve therapeutic outcomes, said Chelsea Tersavitch, PA-C, in a statement presented at the American Academy of Physicians. Associates (AAPA) 2023 Annual Conference was held May 20-24 in Nashville, Tennessee.

Although the connection between diet and physical health (eg iron deficiency leading to anemia) is known, many clinicians may not consider the link between diet and mental health. Tersavich, a psychiatrist at Mindbloom Inc., presented research findings showing that nutrition and a healthy gut microbiota are important for the prevention and treatment of mental health conditions, including depression, anxiety, and cognitive issues (Table 1).

“While there are still many unknowns in this area, what is known can be used to help our patients develop personalized plans to prevent or manage mental health in conjunction with other therapies,” said Tersavich. She emphasized that the use of dietary supplements has a significant impact on patient outcomes; In most cases, data are lacking to support specific supplemental dosages.


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Table 1. The role of micronutrients in mental health

Micro energy Function Supplement
Metal • Developmental deficits can cause changes in the hippocampus, corpus striatum, which can lead to anxiety, depression, sleep disorders, and psychosis.
• They can cause fatigue and depression in adults
• Iron-deficient mothers during pregnancy should supplement with prenatal vitamins containing 27 mg of iron per day.
Magnesium • Depletion can lead to NMDA overactivity which in turn leads to:
– Depression
– Sleep problems
– Swelling
– Anxiety
• Supplementation has shown mixed results.
Omega fatty acids • Low levels associated with bipolar disorder and depression • Supplementation has preventive and therapeutic effects on depression.
• Supplementation in bipolar disorder has mixed results
• Atlantic salmon consumption is associated with decreased emotional activity and cognitive stress
Vitamin B1 • Deficiency may lead to CNS changes (beriberi and Wernicke’s encephalopathy).
Vitamin B3 • Deficiency can lead to pellagra and dementia.
Vitamin B6 • Deficiency can lead to confusion, depression and anxiety.
• Overdose is neurotoxic.
Vitamin B9 • Deficiency can affect neural development (in utero) and increase the risk of depression
Vitamin B12 • Improves cerebral and cognitive functions in geriatrics
• Borderlines develop signs of cognitive changes in adolescents.
• Deficiency can lead to fatigue, depression, depression, memory loss.
• Associated with mania and psychosis
• Comorbid folate deficiency contributes to depressive symptoms; High levels of folate can mask B.12 lack of
Vitamin C • Anxiety-related deficits in healthy young adults and patients with T2D • 2-week supplementation reduces anxiety symptoms
• In patients with T2D, vitamin C + E also reduces symptoms of depression
Vitamin D • Lower levels associated with depression and anxiety systems • Ergocalciferol (D2)
– 4,000 IU/d or 25,000 IU/w
‒ 8,000 IU/d or 50,000 IU/w for populations at risk (>70 years of age, obesity, malnutrition)
Zinc • Low levels associated with clinical depression and anxiety • Supplementation may affect SSRI efficacy (SSRI + zinc showed greater improvement than SSRI + placebo)
CNS, central nervous system NMDA, N-Methyl-D-aspart; SSRIsselective serotonin reuptake inhibitor; T2DType 2 diabetes

Additional micronutrients to consider supplementing include chromium (depression), iodine (thyroid function), lithium (reduces suicidality, aggression and impulsivity) and selenium (lower mood and anxiety), according to Tersavich.

The Role of the Gut-Microbiome

The bidirectional relationship between the brain and the gut is well known. The microbiome is affected by genetics and antibiotics, and now studies suggest a link between a poor gut microbiome and depression.

“We generally improve gut health with a general dietary change: more high-fiber foods like fruits, vegetables, and whole grains, with a variety of bright colors,” Tersavich said. If you can, eating fermented foods like sauerkraut, kimchi, and kombucha is encouraged. Alternatives to improving the gut microbiome include getting enough sleep and reducing stress levels. “If people can afford it and want to try probiotics, look for 1 billion + colony-forming units of many different species,” Tersavich added.

Assessment and management of malnutrition

The clinic plays a key role in addressing malnutrition and eating disorders that contribute to mental health disorders, Tersavich explained. Strategies to identify cases include a 24-hour diet diary, food journal, medical assessment, assessment of financial and social barriers, and food quality assessment.

A 24-hour dietary recall requires the patient to record all meals and beverages on a typical day. Questions to ask include:

  • What is your first meal? second? third? Any snacks?
  • What did you eat in particular? what did you drink
  • Estimate the portion size of each food/drink item
  • Ask in detail how the food is prepared
  • Have you fasted or stopped eating for any reason?
  • Is this a typical day? If not, how does it differ?

Medical evaluation includes laboratory tests for a complete blood cell count, a comprehensive metabolic panel, and micronutrient levels (eg, vitamin D and B).12/ folate), and thyrotropin. Taking a thorough history that evaluates for celiac disease, eating disorders and dental/oral disorders or complaints is also important, Tersavich said. Major weight changes and a history of bariatric or other gastrointestinal surgery that may cause eating disorders should also be noted.

When a patient consumes a high-quality diet, it can be affected by social health factors, including living conditions, financial status, work/employment, and social support. According to Tersavich, these factors should be taken into account during the psychosocial evaluation. Simple options for improving nutritional and mental health are shown in Table 2.

Table 2. Malnutrition and control of poor eating habits

Discuss a Mediterranean-style diet or supplement
Elderly and outpatients
• Meals on Wheels
• Mom’s wheels
• Local/State programs
Food assistance programs
• WIC, SNAP, TEFAP
• Check out local programs (eg, 912 FoodPharmacy).
• Cooking, gardening and other group classes
SNAPSupplemental Nutrition Assistance Program; TEFAP, Emergency Food Assistance Program; PoleNutrition program for women, infants and children

Exercise, mindfulness techniques and socialization also play a role in a holistic approach to mental health, Tersavich said. Ideally, one should aim to obtain nutrients from whole foods rather than supplements whenever possible and appropriate. “The Mediterranean-style diet seems to be the best option so far,” she said. There may be complex neurobiological mechanisms that require the interaction of multiple factors. If someone wants to try a supplement, have a shared decision-making conversation and weigh the risks and benefits for each person.

Ref
Tersavic C. A closer look at the role of nutrition in mental health. Presented at: AAPA National Conference; May 20-24, 2023; Nashville TN.

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