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Dr. I am sooo tired all the time!
Dr. I never feel good anymore!
Dr. I cannot sleep!
Dr. I cannot remember anything!
Dr. I never eat anything but I keep getting fatter!
I did a study with new patients once. I walked in and without saying a word showed them a card with these statements. Most were amazed, usually at least four often all five of these complaints were their reason for our consultation. What does this constellation of symptoms mean? Should I call the CDC? Am I witnessing the evolution of some new disease? As I tell patients, No! It is not Lyme’s disease, chronic fatigue, dementia, yeast taking over your body or even toxins stuck to the colon wall. Despite whatever “current” ineffable internet twaddle you may have read. Remember an old axiom you are what you eat!
Food is a very effective and underutilized intervention in mental health. Physicians want to help patients have more resilient brains and bodies; part of this is the intake of whole foods. This means helping get patients off processed foods, off of white carbohydrates, and off of certain vegetable oils.
Though the field is in its infancy food medicine and psychiatry is increasingly being embraced by clinicians and researchers, as a paper published earlier this year in the Lancet Psychiatry attests. "Although the determinants of mental health are complex," the authors wrote, "the emerging and compelling evidence for nutrition as a crucial factor in the high prevalence and incidence of mental disorders suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology." Other recent work found that simply discussing diet with a counselor for just 6 hours over the course of 2 years dropped Beck Depression Inventory scores by 40% in elderly patients with depression. The data are very promising that we can positively influence mental health through dietary interventions.
A number of studies have linked the Mediterranean diet (high in fish oils, nuts, grains and moderate red wine intake) with advantageous effects on neurologic and mental health. There is recent work reporting that adults who followed the Mediterranean dietary patterns had a significantly reduced risk of developing depression (40%-60%). Also, a 2014 meta-analysis of Deakin University in Melbourne, Australia, found that 57% of the randomized controlled trials on this dietary pattern reported improved long term depression outcomes, levels comparable to those of drug trials. These data are doubly promising given that dietary interventions are very low-risk. When taken together, most of these dietary pattern studies, which have been conducted all over the world, consistently show that traditional, pre-processed diets are the healthiest, especially for the brain. With that in mind here is an anecdotal case of a young woman I have treated for years. Mrs. Tofu is a 37-year-old psychologist with a long history of treatment-resistant depression, (treated by multiple physicians), with severe allergies and asthma. After she started on a self-prescribed paleo diet, a diet mimicking what our hominid ancestors would have eaten, (e.g. meat, nuts, berries), not only did she lose a documented 40 pounds, but the long standing depressive symptoms resolved without my prescribed adjunct medications. She reported improvement in her allergy symptoms as well. I say anecdotal even though this is a firsthand account for I have seen weight loss, allergy relief and proactive empowerment alone relieve depressive symptoms. However, the symptomatic relief is generally not to this degree or this interval of time, 3.7 years as of this month.
Here is a simple rhyme for remembering a healthy brain-food diet: Make me lean, make me mean and give me daily seafood, nuts, greens and beans (and if I am good two and two! That is two ounces of dark chocolate and two cups of coffee). I see it often in clinical practice patients start a healthier diet or brain diet and they feel their focus, energy, self-confidence, attitude, motivation even their sleep and sex lives improve. Is this secondary to dietary change or the involvement in their own self-care and wellbeing? I personally believe it is both. In the final analyst most patients improve in one way or another. A caring physician can ask for little more than this.
Evolution has shaped the human diet. Hominid diets have changed drastically through millions of years of evolution. We started with plants, insects, and larvae; but around 2 million years ago we began incorporating meats into our diets, contributing to the development of the advanced hominid brain. Then 1 to 2 million years ago we added tubers and bulbs. Finally, around 6000-10,000 years ago, agriculture was developed and we added grains, dairy, and legumes to our diets.
But only in the past 100 years has our diet drastically switched from a whole foods diet to one that is more processed and high in refined carbohydrates; including more vegetable fats rather than meat fats; and preservatives, emulsifiers, and other additives, which appear to have contributed to a decline in our collective health.
The backstory of 20th century grain processing is an inane one. Once-nutritious kernels were stripped of their nutrients as new refining practices emerged, only to have specific vitamins added back artificially, given the health problems associated with overly refined grains. Grains and other foods have been processed and preserved for thousands of years, but by using much healthier means. For example, fermentation of grains and letting them sprout greatly increases nutrient availability
Thus we ask: What food was most responsible for Homo sapiens' brain evolution?
Answer: Specifically Protein, often from shellfish.
Early humans evolved occurred in Africa’s Great Rift Valley. Over millennia the rift produced savanna where only primordial jungle had existed. Now with our upright posture and tool us, we were poised to take advantage of many new things such as scavenged marrow and brain matter, locked away in bone and forbidden to less intelligent predators. Also in close proximity was a seacoast offering reliable access to seafood, oysters and shellfish in particular, which glutted our brains with omega-3 fatty acids and cholesterol (our brains are composed of 60% fat).
Oysters and other mollusks are also very high in nutrients, including B12, which is commonly deficient in people consuming vegan or vegetarian diets and is necessary for myelin and neurotransmitter function. Oysters can be an exceptional option for these people who are avoiding meat for moral reasons; oysters do not have highly developed nervous system. Thus, many neuro and electrophysiology researchers have demonstrated they have essentially no response to pain.
Seafood: Seafood in general is packed with brain-healthy omega-3 fatty acids. These healthy fats are also abundant in plants like chia and flax, but plant-based sources are not as easily or efficiently converted to docosahexaenoic acid, an important structural component of neuronal membranes. Docosahexaenoic acid also influences the expression of brain-derived neurotrophic factor, which benefits people who have mood and anxiety disorders.
Bivalves like mussels, scallops, oysters and clams are human’s best source of vitamin B12 as well as zinc: Six oysters (only about 10 calories each) provide 240% of our recommended daily B12 intake and 500% of our recommended zinc intake! Seafood is also a leading dietary source of vitamin D (we don't get it all from the sun) as well as iodine and chromium. For those of you concerned about mercury in fish: A moderate intake of small fish like sardines, anchovies, and herring, which do not accumulate toxic levels of mercury is a good option.
Leafy greens: A great base for a brain-food diet, leafy greens are a good source of fiber, folate (derived from the word foliage), magnesium, and vitamin K. Perhaps surprising, kale, mustard greens, and bok choy provide the most absorbable form of calcium on the planet, more so than milk. Greens also provide flavanols and carotenoids that have beneficial epigenetic influences (e.g., including upping hepatic toxin processing). One cup of kale provides 600% of daily vitamin K, 200% of vitamin A, and over 100% of vitamin C, all for only 33 calories. For those who are greens-phobic try new methods to make them more appetizing: sauté them with olive oil and garlic; put them in a smoothie; bake some kale chips.
Nuts: Nuts had a bad rap for a while because of their high fat content. But, new studies show we have overestimated the caloric content of nuts. Anytime you look at the calories in nuts, take off 25%. Nuts are packed with healthy monounsaturated fats. They help keep us full and also aid in absorbing fat-soluble nutrients. Nuts also provide fiber as well as minerals like manganese and selenium. A serving of 22 almonds (just 162 calories) contains 33% of our recommended vitamin E, plenty of protein, and minerals, including iron. One study from 2013 found that the Mediterranean diet augmented with nuts is associated with significantly higher brain-derived neurotrophic factor levels in patients with depression.
Legumes: Many people are eating far too much and the wrong types of meat, nuts and legumes are a great alternative source of protein and nutrients. Small red beans in particular are the top antioxidant-containing food, while just 1 cup of lentils contains 18 g of protein and 90% of the recommended daily folate intake.
Are Plant-Based Diets Healthier?
Some data suggest that vegan and vegetarian diets are associated with improved mood. However, as previously mentioned, these dietary patterns can result in B12 deficiency, which has been associated with brain atrophy and developmental delay. Hence, supplementation is important in this population. Vegetarianism has also been linked with depression, anxiety, and eating disorders, as well as increased healthcare utilization and worse quality of life. These negative associations also could be due to the fact that it's harder to absorb nutrients like zinc, iron, and certain omega-3s from plants.
The notion that the vegan diet is the healthiest diet on the planet is incorrect for many reasons. The average American consumes over 200 pounds of meat and fish per year. That is not sustainable for the planet especially if you look at the amount of beef we consume. We want to help patients use beef and seafood more as flavorings on top of a plant-based diet. This type of diet echoes Thomas Jefferson's approach to nutrition, “I have lived temperately, eating little animal flesh, and that he is consumed not as an aliment, so much as a condiment for the vegetables which constitute my principal diet."
A modest amount of meat in the diet has its benefits, including nutrient availability: Hemoglobin-derived iron is up to 40% more absorbable than plant-based iron. Unlike most plants, meat provides all of the amino acids necessary for protein synthesis. It is important to seek out leaner, grass-fed meats if one has the means. Aside from the grim state of large-scale meat companies, the packed cages, animal cruelty concerns, the overuse of antibiotics, industrially raised animals reared on corn instead of grass have excessive intramuscular fat to a degree not found in nature, which is not as healthy for us.
What about Gluten?
Gluten: One of today's trendiest health topics. There are some real issues with gluten; I think most people can tolerate whole grains and gluten quite well. About 2% of Americans have celiac disease and are allergic to gluten, even in very small amounts. Gluten sensitively is a bit more controversial; it's reportedly found in up to 6% of adults, yet 11% of adults now purchase gluten-free foods.
One related area that may deserve particular attention is the possible relationship between gluten and psychosis. The CATIE trial demonstrated that patients with schizophrenia have significantly elevated antigliadin antibodies (gliadin is a component of gluten); over 23% of schizophrenic patients had moderate to high antigliadin antibodies compared with just 3.1% of controls. Maybe we should be checking our psychotic patients for celiac disease. A case in point: A very thin, 37-year-old woman patient of mine with no psychiatric history had become increasingly paranoid and psychotic over about a year. She had lost her job, become homeless, and alienated family and friends. She underwent numerous drug treatment trials to no avail. Eventually she arrived at the hospital, and because of her weight, an endocrinologist suggested celiac disease. Though initially skeptical, the patient agreed to go to the state hospital where she was kept on a gluten-free diet for 3 months. She stabilized. Subsequently she was discharged and returned to her gluten-heavy diet. Once again her antigliadin antibodies skyrocketed and once again she ended up in hospital. They called and asked me about her meds which I limited and specified a gluten free diet. The patient quickly remitted. Granted this was an unusual case and for most people without celiac disease, going gluten free will produce little effect. All of these gluten-free options are great for people with celiac disease, but otherwise I don't think that a gluten-free muffin is particularly healthier than your white flour muffin in terms of brain health.
Fermented Foods, the Microbiome?
Like gluten, discussion of the microbiome now appears almost daily in lay and professional media. Our microbiomes contain well over 1 million genes, compared with our 23,000 genes. Furthermore, the commensal microbiome accounts for 90% of the cells in our bodies. Among other functions, these gastrointestinal symbiotes help form and maintain our immune system and aid in digestion, so their health is critical to our health. The understanding of how microbiota contribute to our mental and medical well-being is rapidly advancing.
For example, there is considerable overlap between irritable bowel syndrome and depression and anxiety. Most experts’ contention is that they are the same pathology expressed in different phenotypes. Gut pathogens cause inflammation and increase factors like IL-6 and interferon gamma, findings also seen in depression, ultimately reducing the conversion of tryptophan to serotonin. We find more and more that infection and chronic inflammation may be at the core of conditions such as depression and anxiety. It is possibly many of the chronic and deadly medical diseases that plague mankind are infectious disease based, thus, the concept of probiotics, psychobiotics or the idea that microbiota can influence physical and mental health needs more study.
One of the most powerful interventions to alter our microbiome is diet. Research shows that stressed mice experienced changes in the gastrointestinal microbiota, reflecting the gut-brain relationship. There are 260 million neurons connecting the gut and the brain; furthermore, many commensal gut bacteria make neurotransmitters and communicate with the brain via the vagus nerve. I don't know what they're saying to us but let's just say that if you get a fecal transplant, you want to get if from a happy, mellow person.
Although the science of probiotic therapies is relatively young, it's clear that these commensal organisms co-evolved with us and are adapted to our diet. One study out of The Netherlands found that a 4-week regimen of multispecies probiotics can reverse cognitive reactivity to sad mood. Another study explored what would happen if a group of African Americans in Atlanta swapped diets with a group of rural black South Africans. The investigators were curious to see whether dietary differences could help explain the drastically differing rates of colon cancer between the two populations (65:100,000 in African Americans vs < 5:100,000 in rural South Africans). The South African diet was high in fiber and prebiotics, while the American diet was much higher in junk food, refined carbohydrates, and animal fats. Within 14 days of switching to the South African diet, healthy butyrate-producing microbial species increased by 258% in the American population. Butyrate is a byproduct of bacterial fermentation in the colon and is thought to protect against colon cancer.
6 FOOD QUESTIONS ANSWERED
Question 1: What's healthier: raw food or cooked food?
What could be more human than a cooking fire? Cooking tends to increase nutrient availability and decrease toxins, many grains as well as potatoes are actually poisonous raw. Some foods, greens especially, can be healthier raw because cooking breaks down nutrients. I recommend a mix of cooked and raw foods to my patients; however, we invented fire and started cooking for a reason.
Question 2: Should we worry about recommending too many high-cholesterol foods like oysters, particularly in people with high cholesterol?
All things considered, dietary cholesterol has among the least affect on blood levels of cholesterol. One of the main drivers of heart disease is high triglycerides, which come heavily from eating glucose and fructose. That being said, if patients have high cholesterol or an abnormal cardiovascular condition, then a low saturated fat and cholesterol diet is prudent.
Question 3: What about certain spices being healthy?
You cannot just tell people to eat grass-fed beef; spicing is important both for flavor and possibly health. Evidence suggests that curcumin, an ingredient in turmeric, increases brain-derived neurotrophic factor levels. Other research has found that populations that eat more curry have a decreased risk for dementia, while rosemary extract may help prevent cognitive impairment. Many spices seem to have healing properties.
Question 4: Is coffee and tea consumption healthy?
The data on coffee are very good. I had a patient who was drinking nine Diet Cokes a day; I switched him to coffee and flavored water, low calorie and healthy flavonoids. Tea is one of my favorite ways to try to get people off of soda; there are endless tea verities’ available with many antioxidant properties. Earlier this year, a study out of Japan reported that higher consumption of green tea is associated with a lower risk for dementia, mild cognitive impairment and high blood pressure. Most coffee data have been positive, even with high intake, though, transient increases in blood pressure and anxiety can occur.
Question 5: Is milk healthy for the brain?
Milk consumption is an interesting adaptation in the human race since the advent of agriculture and lactase persistence in adults, meaning you can digest lactose into adulthood, has evolved six separate times over the past 6000 years. Clearly there is an evolutionary population advantage to it. Milk and dairy consumption may help explain why modern humans are so much taller than other hominids.
Question 6: What about fasting?
Although the "Food and the Brain" session at the American Psychiatric Association annual meeting focused on what to eat in the interest of brain health, intermittent fasting might also be beneficial for the brain. In addition to helping maintain a healthy weight, fasting induces ketosis. Ketone metabolism has been shown to be beneficial for the brain and improve cognition in patients with mild cognitive impairment or Alzheimer disease. Keep in mind that fasting can come with risks for some people, particularly diabetics, and should be discussed with your physician.
Finally, can you eat to build a better brain? I think that you can if you focus on dietary patterns. We need to identify and increase their consumption of nutrient-dense foods and to eat the rainbow. I do not know of anything else in medicine that can potentially decrease the risk of depression in a population by 40%. Perhaps diet, exercise and laughter are as close as we get to true prevention in medicine and psychiatry.
THE MEDITERRANEAN DIET AND SEAFOOD: Marc J. Crupie, M.D.
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