Mental Health: Where Nutrition meets Psychiatry By Nicola Walters, Registered Dietitian

Key Focus Areas Overview of Global & SA Statistics Analysis of the Evidence Sugar & Refined Carbohydrates Fat: dietary quality & quantity Maternal Health Gene SNPs Key nutrients Understanding the complex Biological Pathways Gut Brain Connection Inflammatory Pathways Oxidative Stress Psychiatric Medications & Nutrition Related Side Effects Putting this into practice Copyright 2017 Nicola Walters Nutritional Solutions

Copyright 2017 Nicola Walters Nutritional Solutions What is Mental Health? Two widely established systems for classifying mental disorders: Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) Chapter V consists of 10 common groups i.e. F3: Mood affective disorders or F4: Neurotic, stress-related and somatoform disorders The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the American Psychiatric Association (APA) Neurodevelopmental disorders; Schizophrenia spectrum and other psychotic disorders; Bipolar and related disorders; Depressive disorders; Anxiety disorders; Feeding and eating disorders; Sleep wake disorders. World Health Organization (2005). WHO Resource Book on Mental Health: Human rights and legislation. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5 25.

Current Statistics Globally Depression affects 300 million people 4.4 % of the worlds population Lower income countries growing Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Common mental disorders refer to two main diagnostic categories: Depressive disorders Anxiety disorders Highly prevalent Impact mood or feeling Mild to severe Months to years Copyright 2017 Nicola Walters Nutritional Solutions

Mental Health America of the Heartland, 2017

Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017.

Copyright 2017 Nicola Walters Nutritional Solutions South African Context In South Africa, 1 in 3 people will experience a mental illness in their lifetime, and 23 people commit suicide each day Psychiatric conditions are ranked 3rd in their contribution to the burden of disease, after HIV and AIDS and other infectious diseases 16.5% of South Africans suffered from common mental disorders such as depression and anxiety in the last year and 17% of children and adolescents suffer from mental disorders SADAG (2017) The vicious cycle of poverty and mental illness: The sad state of care in SA Mental Health & Poverty Project (MHaPP) Research Statistics from 2005 Calendar year.

South African Context: Access to care SADAG (2017) The vicious cycle of poverty and mental illness: The sad state of care in SA Mental Health & Poverty Project (MHaPP) Research Statistics from 2005 Calendar year.

Heavy Burden: Only increasing Depression is highly comorbid with: heart disease type 2 diabetes obesity metabolic syndrome Common underlying pathways linked to diet SADAG (2017) The vicious cycle of poverty and mental illness: The sad state of care in SA Mental Health & Poverty Project (MHaPP) Research Statistics from 2005 Calendar year.

Bidirectional association between metabolic syndrome and mental health disorders Medication side effects and social repercussions are contributing environmental factors but there are a number of shared underlying neurological and physiological mechanisms that explain the high comorbidity Inflammation is a state shared by both disorders & disruptions of neuroregulatory systems as well as HPA axis Treatment should address aspects of both mental health and metabolic disorders

Analysis of the Evidence

Sugar & Refined Carbohydrates 70 000 post-menopausal women Diet analysed for GI, GL and compared with depression scores Consumption of dietary fibre, whole grains, vegetables and fresh fruits was associated with a decreased risk of depression Postprandial hyperglycemia can lower plasma glucose to concentrations that compromise brain glucose (neuroglycopaenia) This triggers the secretion of autonomic counterregulatory hormones such as adrenaline, cortisol, glucagon, and growth hormone Counterregulatory hormone responses can cause anxiety, irritability, and hunger & neuroglycopenia can result in cognitive impairment, mood and behavioral changes & fatigue

Copyright 2017 Nicola Walters Nutritional Solutions Sugar & Refined Carbohydrates Studies have indicated that regular consumption of a diet with a high glycaemic load is associated with higher plasma concentrations of C-reactive protein (CRP), a marker of low-grade inflammation. Insulin resistance in brain induces dopaminergic dysfunction leading to anxiety and behavioural disorders poor glycaemic control can increase insulin resistance in the brain cells McMartin, S. E., Jacka, F. N., & Colman, I. (2013). The association between fruit and vegetable consumption and mental health disorders: evidence from five waves of a national survey of Canadians. Preventive medicine, 56(3), 225-230. Kleinridders A., Cai W., Cappellucci L., Ghazarian A., Collins W.R., Vienberg S.G. Insulin resistance in brain alters dopamine turnover and causes behavioral disorders. Proceedings of the National Academy of Sciences of the United States of America. 2015;112:3463 3468

Dietary Fat: Quality & Quantity 21 studies in meta-analysis Dietary pattern characterized by a high intake of fruit, vegetables, whole grain, fish, olive oil, low-fat dairy and antioxidants associated with a decreased risk of depression. Dietary pattern characterized by a high consumption of red and/or processed meat, refined grains, sweets, high-fat dairy products, butter, potatoes and high-fat gravy, and low intakes of fruits and vegetables is associated with an increased risk of depression. More RCTs and cohort studies are required

Dietary Fat: Quality & Quantity Higher intakes of saturated fatty acids (SFA) have also been associated with cognitive impairment. Cross-sectional and longitudinal correlational studies indicate that higher intakes of SFA in young adulthood, mid and later life are associated with worse global cognitive function, impairments in prospective memory, memory speed and flexibility and an increased vulnerability to age related deficits and neurological diseases including dementia and Alzheimer s disease. Okereke, O.I.; Rosner, B.A.; Kim, D.H.; Kang, J.H.; Cook, N.R.; Dietary fat types and 4-year cognitive change in community-dwelling older women. Ann. Neurol. 2012, 72, 124 134.

Dietary Fat: Quality & Quantity In contrast, higher intakes of polyunsaturated fatty acids (PUFA) and higher PUFA to SFA ratios are associated with better memory function and a reduced risk of memory impairment More specifically, higher intakes of omega-3 PUFA compared to omega-6 PUFA have been linked to a lower risk of cognitive decline and Alzheimer s disease. These studies indicate that the quality and type of fat may impact cognition more than total fat intake but this is difficult to ascertain in human populations. Luchtman, D.W.; Song, C. Cognitive enhancement by omega-3 fatty acids from child-hood to old age: Findings from animal and clinical studies. Neuropharmacology 2013, 64, 550 565

Maternal Health Does the impact of early life nutritional exposures extend from physical to mental health? n = 23,020 Pre and post-natal diet quality and children s mental health at 18mo, 36mo and 5yrs Maternal and Paternal Age Maternal Education Parental Income Marital Status Maternal depression and anxiety Maternal smoking Maternal job Parity and gestational length Parental Locus of control

Copyright 2017 Nicola Walters Nutritional Solutions Summary of Findings Higher intakes of unhealthy foods by mothers during pregnancy are related to increased externalising behaviours in children Higher intakes of unhealthy foods by children are related to increased internalising and externalising behaviours in children Jacka et al. (2013) JAACAP Internalising behaviours are inhibited and overcontrolled; nervous; show anxious temperament; worry or fear and are withdrawn. Externalising Behaviours are under-controlled; more challenging temperament, impulsive or reactive behaviour that can be aggressive or oppositional.