Feeling good has a lot to do with what you eat (and what you don’t eat).

The nutrition space has become quite crowded in the past decade. There are thousands of wellness bloggers, books and websites all ready to inform, and sometimes confuse as all. As a Dietitian who led nutrition at a major medical institution, any advice that I provide must always have evidence to back it up. As I often say, my patients are not interested in my opinion, but rather, my interpretation to them on the science behind what’s good, and what’s not so good in the world of food. Most of my patients are interested in what can help them lose weight, prevent disease, and live longer. However, I love it when my patients are the ones that come to me asking how diet can help their overall mood, for they must know and appreciate the fact that if your mental health is not good, other comorbidities may follow. In fact, studies show that depression is a leading cause of disability worldwide.

More concerning, some studies even suggest that depression may take the same deadly path that smoking and obesity do. An annual physical typically involves a weight check and questions about unhealthy habits like smoking, but a new study from UC San Francisco suggests health care providers may be overlooking a critical question: Are you depressed or anxious?

Anxiety and depression may be leading predictors of conditions ranging from heart disease and high blood pressure to arthritis, headaches, back pain and stomach upset, having similar effects as long-established risk factors like smoking and obesity, according to the new research. 

In the study, first author Andrea Niles, PhD, and senior author Aoife O’Donovan, PhD, of the UCSF Department of Psychiatry and the San Francisco VA Medical Center, looked at the health data of more than 15,000 older adults over a four-year period.

They found that 16 percent (2,225) suffered from high levels of anxiety and depression, 31 percent (4,737) were obese and 14 percent (2,125) were current smokers, according to their study published in the journal Health Psychology on Dec. 17, 2018.

Participants with high levels of anxiety and depression were found to face 65 percent increased odds for a heart condition, 64 percent for stroke, 50 percent for high blood pressure and 87 for arthritis, compared to those without anxiety and depression.

“These increased odds are similar to those of participants who are smokers or are obese,” said O’Donovan, who, with Niles, also is affiliated with UCSF Weill Institute for Neurosciences. “However, for arthritis, high anxiety and depression seem to confer higher risks than smoking and obesity.”

Isn’t it time to bring diet into the mental health discussion?

The connection between food and mood.

The science behind the food as it impacts depression is strong, and consensus https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592666/ amongst major organizations is that food plays a major role in mental health.

In 2015, the journal Lancet https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/fulltext  published that nutritional medicine should be a main focus in psychiatry. The SMILES trial https://tandfonline.com/doi/full/10.1080/1028415X.2017.1312841, published last year, showed that when diet quality improved, depressive symptoms decreased. Additionally, a meta-analysis https://insights.ovid.com/crossref?an=00006842-900000000-98656 which reviewed 16 randomized controlled trials in over 45,000 individuals, showed that boosting nutrients, losing weight, and reducing unhealthy fats, fast foods, and refined sugars helped to mitigate depressive symptoms and improve mood.  

Bad eating habits start in childhood.

While eating better can improve mood, poor mood can impact eating habits as well.

Therefore, the connections between food and mood can sometimes be a chicken and an egg approach. Though plenty of strong studies show the benefits of a nutrient-dense diet on quality of life and mood, there is also evidence that poor mood can cause someone to make unhealthy choices in the first place. Eating due to stress, anxiety, anger, or sadness is real, and often includes “feel good” foods that have been programmed in childhood or traumatic events. For example, if your mom gave you a cookie or a chocolate bar every time you skinned your knee, guess what you’ll want to eat when you’re in need of soothing? In fact, one study https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415834 found that people with depressive symptoms ate more chocolate than people that did not.

Childhood can also bring in habits that last a lifetime, including binge eating on unhealthy foods.  A 2016 study https://www.sciencedirect.com/science/article/pii/S1471015316300381?via%3Dihub found that parental ignoring and weight teasing were large predictors of binge eating.

Therapists are wonderful in understanding the cause and effect of our early years. Understanding and dealing with how these years impact food choices will only benefit therapy.

The Best Feel Good Foods

A Mediterranean Diet Pattern

Several studies show a connection between consumption of a Mediterranean diet and positive mood. Perhaps this is because the diet has such an impact on overall brain health. One study https://www.aan.com/PressRoom/Home/GetDigitalAsset/12662 found that people who ate more fruits, vegetables, and whole grains had lower rates of depression over time. These are just three of the main components of the diet, in addition to fish and skinless poultry, legumes, fish and small amounts of red wine. Finally, a large 2018 study  https://www.nature.com/articles/s41380-018-0237-8 found that a Mediterranean plant-based approach (omitting fish and chicken) may produce mental health benefits as well. Another approach is to adopt the MIND diet. MIND is a combination of the DASH and Mediterranean diets and adherence to it has shown impressive brain-related benefits in several studies https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.14922, especially in older populations.

Omega 3 Fatty Acids

An animal study https://www.nature.com/articles/tp20119 out of the Indiana School of Medicine found that omega 3 supplementation could have a potential “therapeutic benefit” for both anxiety and alcohol abuse. Another https://www.tandfonline.com/doi/full/10.1080/15548627.2017.1345411 demonstrated the impressive anti-inflammatory impact of regular consumption of fatty fish, which is high in omega 3 fatty acids. Inflammation is the base of the majority of diseases worldwide and plays a role in depressive disorders https://www.psychologytoday.com/us/blog/urban-survival/201701/new-research-shows-depression-linked-inflammation. Other sources of omega 3 fatty acids include chia, hemp, and flax seeds, walnuts, and lake trout. To get the best bang for your fish buck, always choose wild sources.

Vitamin D

Several studies https://www.sciencedirect.com/science/article/pii/S0306987714003351?via%3Dihub  have linked vitamin D deficiencies to increases in depression https://www.jamda.com/article/S1525-8610(18)30579-6/fulltext.  While vitamin D is poorly absorbed through food sources, it is well absorbed through the rays of the sun and supplementation with D3. Since spending too much time in the sun can increase the risk for melanoma, it is advised to have your vitamin D levels checked and then supplement with a D3 option. If you are taking a fish oil pill, you should pair the two together. Doing so will enhance the absorption of vitamin D, a fat-soluble vitamin.

Consider raw foods.

Even the method in which food is prepared may make a difference. A 2018 https://www.frontiersin.org/articles/10.3389/fpsyg.2018.00487/full study found that raw foods were more beneficial to mental health than cooked, canned, or processed foods. Authors believe that certain cooking methods can sap nutrients, and since nutrients are key in mental health outcomes, diminishments of any kind may in fact impact mood. While some foods, like tomatoes, have better nutrient density when cooked, many foods retain their full benefit when eating au natural.

Feeling good begins in the gut.

Getting more fermented foods in the diet (such as tempeh, miso, sauerkraut and pickles) can enhance gut health, and gut health may, in turn, impact mood. A 2019 study https://www.nature.com/articles/s41564-018-0337-x (the first study population level study linking gut bacteria to mental health) found that certain gut bacteria could produce neuroactive compounds that could impact depression and depressive symptoms. The study, which looked at genomes of more than 500 bacteria isolated from the human intestinal tracts, found clear connections between quality of life and gut bacteria. One bacterium in particular, for example, produced metabolites specific to dopamine, a feel-good neurotransmitter. Aside from fermented foods, a variety of fruits, vegetables, and whole grains (all high in fiber), as well as avoidance of fried foods, sugar and refined grains, can improve gut health.

A supplement can’t replace a healthy diet.

So many of my patients think their daily supplement will make up for poor dietary choices. While studies show the fault of such thinking, a new one shows that it is even more true when it comes to mental health. The 2019 MooDFood study https://www.moodfood-vu.eu/nutritional-supplements-cannot-prevent-depression found that while a healthy diet can benefit mental health, popping nutritional pills won’t. With the exception of Vitamin D3, which is better absorbed in a supplement form, I recommend my patients chew their nutrients for maximum benefit.

Here’s what to ditch.

Foods that contribute to inflammation may spell danger for mental health as well. Sugar, fast, fried, and ultra-processed foods and trans fats have all been implicated as potential contributors to depression. A 2019 study https://www.tandfonline.com/doi/full/10.1080/09637486.2019.1570085 found that individuals that reported unhealthy food habits were more likely to report moderate to severe physiological stress. Not surprising, the study showed that that individuals with a healthy diet were not as likely to report adverse mental health outcomes. Additionally, sugar holds addictive properties and has been proven to increase the risk of several chronic conditions.

Exercise is a powerful metal health boost to a healthy diet.

A 2018 study https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30227-X/fulltext found that regular physical activity helped to improve mental health, with participation in team sports showing the best outcomes (implying the importance of the social aspect of exercise). The study, in over 1 million individuals, showed that exercise helped mental health, regardless of age, race, income, gender or education level. Exercising at least 30-60 minutes, at least 3-5 times per week saw the greatest benefit.

Dietary modifications are an enhancement to behavioral therapy, not a replacement.

A team approach to behavioral therapy must include a multidisciplinary team consisting of both a therapist and a dietitian. While dietary enhancements can help therapy, it alone cannot fix a mental health problem. This approach is truly no different from the modalities used for any behavior change, such as weight loss, for example. While a physician or dietitian can help alter the foods eaten, they can often not impact the mindset the way a therapist can. If you are interested in finding a dietitian in your area, visit https://www.eatright.org/find-an-expert.

Eating well plays a large role ion recovery as well. Many of the poor choices in diet are ones that contain excess sugar, refined carbohydrates or even trans fat. Since these foods have clear connections to a decreased quality of life, keeping them in will only make recovery that much harder. Also, therapists should be aware of some of the addictive properties that have been shown in association with sugar intake in animal studies. Recovering from one addiction is hard enough – getting sugar out as well will help the overall healing process.

Kristin Kirkpatrick, MS, RDN is the Lead Dietitian and manager of Wellness

Nutrition Services at the Cleveland Clinic Wellness Institute in Cleveland, Ohio, and is a Senior Fellow of Meadows Behavioral Healthcare. She is a best-selling author (Skinny Liver: A Proven Program to Prevent and Reverse the New Silent Epidemic – Fatty Liver Disease), an experienced presenter, and an award winning dietitian. Kristin has been seen on shows such as the TODAY Show, NBC Nightly News, and the Dr. Oz Show, and has contributed to several national newspapers and magazines. In addition, Kirkpatrick writes for TODAY.com, the Huffington Post, and US News and World Report, and is a featured expert on Cleveland Clinic’s Health Essentials. Kristin also serves on Dr. Oz’s Medical Advisory Board as well as the Advisory Board for Lose it! Kristin has over 17 years of experience in the health management area and holds an MS in Health Promotion Management from American University. For more visit www.kristinkirkpatrick.com/