Are you asking your patients with depression about their diet? Emerging research says you should. A holistic approach to treating mental health conditions should include a personalized plan to address nutritional deficiencies, improve gut microbiota, and alter eating habits is essential to achieving treatment outcomes, said Chelsea Tersavich, PA-C, in a presentation at the American Academy of Physician Associates (AAPA) 2023 Annual Conference held May 20-24 in Nashville, Tennessee.
Although the correlation between nutrition and physical health (eg, iron deficiency leading to anemia) is well known, many clinicians may not consider the connection between nutrition and mental health. Tersavich, who is a psychiatric PA at Mindbloom Inc, presented research findings showing that nutrition and healthy gut microbiota are important in preventing and treating mental health conditions including depression, anxiety, and cognitive issues (Table 1).
“Although there are still unknowns in this area, what is known can be used to help our patients come up with personalized plans to prevent or manage mental health in conjunction with other treatment modalities,” Tersavich said. She emphasized that consumption of nutrients from food rather than supplements may have the greatest effect on patient outcomes; data is lacking to support specific supplement dosages in most cases.
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Table 1. Role of Micronutrients in Mental Health
| Micronutrient | Function | Supplementation |
| Iron | • Developmental deficiency can cause changes to the hippocampus, corpus striatum that in turn can lead to anxiety, depression, sleep disorders, and psychosis • In adults, can lead to fatigue and depression | • For iron deficiency in pregnancy, mothers should supplement with prenatal vitamins containing 27 mg of iron per day |
| Magnesium | • Depletion can lead to NMDA overactivity that in turn can lead to: ‒ Depression ‒ Sleep issues ‒ Inflammation ‒ Anxiety | • Supplementation has shown mixed results |
| Omega fatty acids | • Low rates linked to bipolar disorder and depression | • Supplementation has preventative and therapeutic effects on depression • Supplementation in bipolar disorder has mixed results • Consumption of Atlantic salmon linked to decreased emotional activation and cognitive worry |
| Vitamin B1 | • Deficiency can lead to CNS changes (beriberi and Wernicke encephalopathy) | |
| Vitamin B3 | • Deficiency can lead to pellagra and dementia | |
| Vitamin B6 | • Deficiency can lead to confusion, depression, and anxiety • Too much is neurotoxic | |
| Vitamin B9 | • Deficiency can affect neurodevelopment (in utero) and increase the risk of depression | |
| Vitamin B12 | • Enhances cerebral and cognitive functions in geriatrics • Borderline levels develop signs of cognitive changes in adolescents • Deficiency can lead to fatigue, lethargy, depression, poor memory • Associated with mania and psychosis • Comorbid folate deficiency contributes to depression symptoms; high folate doses can mask B12 deficiency | |
| Vitamin C | • Deficiency linked to anxiety in healthy young populations and patients with T2D | • 2-week supplementation can reduce anxiety symptoms • In patients with T2D, vitamin C + E supplementation can reduce anxiety symptoms |
| Vitamin D | • Low levels linked to depression and anxiety systems | • Ergocalciferol (D2) ‒ 4,000 IU/d or 25,000 IU/w ‒ 8,000 IU/d or 50,000 IU/w in at-risk populations (>70 years of age, obesity, nutritional deficiencies) |
| Zinc | • Low levels linked to clinical depression and anxiety | • Supplementation can influence effectiveness of SSRI (SSRI + zinc saw higher rates of improvement than SSRI + placebo) |
Additional micronutrients to consider supplementing include chromium (depression), iodine (thyroid function), lithium (reduced risk of suicide, aggression, and impulsivity), and selenium (lower mood and anxiety), according to Tersavich.
Role of Gut-Microbiome
The bidirectional association between the brain and gut is well known. The microbiome is affected by genetics and antibiotics, and research now suggests a link between a poor gut microbiome and depression.
“Ideally, we improve gut health through overall nutritional changes: lots of high fiber food like fruits, veggies, and legumes, with a variety of bright colors,” Tersavich said. “Eating fermented food like sauerkraut, kimchi, and kombucha is encouraged if you are able.” Nondietary options to improve the gut microbiome include getting enough sleep and keeping stress levels down. “If people can afford it and want to try probiotics, aim for 1 billion + colony building units with multiple genus present,” Tersavich added.
Assessing and Managing Nutritional Deficiencies
The clinician plays a key role in managing nutritional deficiencies and eating patterns that contribute to mental health disorders, Tersavich explained. Strategies for identifying issues include the 24-hour dietary recall, food journal, medical evaluation, assessment of financial and social barriers, and quality of food assessment.
The 24-hour dietary recall asks the patient to record all food and drinks consumed on a typical day. Questions to ask include:
- What do you eat at your first meal? Second? Third? Any snacks?
- What did you specifically eat? What did you drink?
- Estimate the portion size of each food/drink item
- Ask specifics about how foods are prepared
- Do you ever fast or skip meals for any reason?
- Is this a typical day? If not, how does it differ?
Medical evaluation includes laboratory tests for complete blood cell count, comprehensive metabolic panel, micronutrient levels (eg, vitamin D and B12/folate), and thyrotropin. Taking a thorough history that assesses for celiac disease, nutritional disorders, and dental/oral disorders or complaints is also warranted, Tersavich said. Major weight changes and a history of bariatric or other gastrointestinal surgeries that may lead to nutritional deficiencies should also be noted.
A patient’s consumption of high-quality food may be affected by social determinants of health including living situation, financial status, job/career, and social support. These factors should be considered during psychosocial evaluation, Tersavich noted. Simple options for improving nutrition and mental health are shown in Table 2.
Table 2. Managing Nutritional Deficiencies and Poor Eating Habits
| Discuss Mediterranean-style diet or supplementation |
| Elderly and homebound patients • Meals on Wheels • Mom’s Wheels • Local/state programs |
| Food support programs • WIC, SNAP, TEFAP • Check for local programs (eg, 912 FoodFarmacy) • Cooking, gardening, and other group classes |
Exercise, mindfulness techniques, and socialization also play a role in the holistic approach to mental health, Tersavich concluded. Ideally, a person should aim to get nutrients from whole foods rather than supplementation when possible and appropriate. “A Mediterranean-style diet so far seems to be a great option,” she said. “There are likely complex neurobiological mechanisms occurring that require the interaction of multiple nutrients. If someone wants to try supplementation, have a shared decision-making conversation and weigh the risks and benefits for each person.”
Visit Clinical Advisor’s meetings section for more coverage of AAPA 2023.
Reference
Tersavic C. Taking a closer look at nutrition’s role in mental health. Presented at: AAPA National Conference; May 20-24, 2023; Nashville TN.
