NHD Issue 149 Nutrition in mental health recovery

CONDITIONS & DISORDERS

NUTRITION IN MENTAL HEALTH RECOVERY When the NHS was founded in 1948, physical health and mental health were largely disconnected, but professional practice and attitudes have now improved significantly with the vast expansion of clinical evidence and advocacy. This article explains how nutrition plays a role in managing symptoms of various mental health conditions, with a special focus on depression.

Every year across the UK, at least one in four adults1-4 experiences mental health problems, with as many as one in six experiencing common mental health problems such as depression, general anxiety disorder, social anxiety disorder, panic disorder, obsessive compulsive disorder and post-traumatic stress disorder.5 Other mental health problems include, but are not limited to, eating disorders, bipolar disorder, psychosis and schizophrenia.6 Symptoms of depression,7 can vary from person to person, but generally speaking, an individual may experience low mood, feelings of guilt or low self-worth and loss of interest in things previously enjoyed, amongst many other symptoms. These persist for at least two weeks and may continue for months or even years, with some experiencing impact on their daily activities.

Victoria Chong Graduate BSc (Hons) Applied Nutrition from Glasgow Caledonian University.

THE ROLE OF NUTRITION IN MENTAL HEALTH

A biopsychosocial approach to mental health recovery is reflected in the clinical guidelines for managing anxiety,8 depression,9 bipolar disorder11 and schizophrenia.10 Healthcare professionals may recommend9,11 referral to a Registered Dietitian for dietary management of a physical health condition, particularly if this is chronic, as coping with chronic conditions can take a toll on one’s mental health.9-11 Whilst nutrition does not cure mental ill health, it can be a key pillar13 in the self-management of symptoms, as well as in the prevention and management of physical health problems in those with mental health conditions, who often face significantly higher risk of developing poor physical health.17

Victoria has a wide range of interests in clinical dietetics and public health nutrition. Her special interests lie in renal nutrition and mental health.

REFERENCES Please visit: https://www. nhdmag.com/ references.html

Table 1: Basing meals around starchy options Aim for 8 to 10 portions a day32,34

One portion for an adult is equivalent to:

Breakfast cereal

3 tablespoons

Porridge oats

3 tablespoons

Bread

1 medium slice

Pasta (boiled)

2-3 tablespoons

Rice (boiled)

2-3 tablespoons

New potatoes (boiled)

2 egg-sized potatoes

Baked potatoes

1 medium size, with skin on www.NHDmag.com November 2019 - Issue 149

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CONDITIONS & DISORDERS Table 2: Portion sizes for plant and animal proteins Aim for two to three servings21,34 a day, of any source of protein

One portion of a good animal source of tryptophan, vitamin B12 and iron is roughly:

Cooked meats, such as beef/mince/pork/lamb/chicken/turkey/liver

1 deck of cards (60-90g)

Cooked white fish, such as cod/plaice/tinned fish

1 palm of hand (140g)

Eggs (yolk included)

2 eggs (yolk included)

Milk

1/3 pint (~200ml)

Cheese

1 matchbox size

Yoghurt/custard

1 standard pot (~150g) One portion of a good plant source of tryptophan and iron is roughly:

Beans, such as baked beans/kidney beans/butter beans/black eyed beans Pulses, such as chickpeas/lentils

4 tablespoons (~150g)

Soya/tofu

4 tablespoons (~100g)

Nuts

1 handful of nuts (~30g)

Nut butters, such as peanut butter

1 tablespoon (~30g)

Some medications may be accompanied by side effects, which may influence an individual's dietary intake, including: • an increased appetite or loss of appetite • nausea • dry mouth • insomnia and fatigue • weight gain • metabolic disturbances such as alterations in glucose and lipid metabolism.18,20 MOOD-MANAGING MEALS

Having regular meals that include starchy foods or wholegrains, a lean protein source and vegetables of various colours, will contribute significantly towards a healthy balanced and nutrient-rich diet.21 Spacing meals out throughout the day and making sure to include breakfast may help with building a routine.

The Eatwell Guide can be a useful reference for planning meals and choosing snacks that support a healthy mind.21 Eating healthily helps reduce the risk of vitamin and mineral deficiencies associated with symptoms of fatigue and irritability, which are also commonly experienced during episodes of depression and hypomania in bipolar disorder.12,14,18,20 40

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START STARCHY

Starchy foods, such as wholemeal bread, potatoes, rice, pasta, cereals and couscous are good sources of carbohydrates and vitamins including thiamine (vitamin B1) and niacin (vitamin B3).

Choosing higher-fibre or wholegrain options provides a steady release of glucose, the body’s primary source of energy, into the bloodstream and prevents slumps in energy levels. Avoiding large portion sizes32 and greasy or cheesy meals may also help prevent this. See Table 1 for portions.

GO GREEN

In terms of managing symptoms of poor mental health, folate (vitamin B9) and iron may help mitigate lethargy and aid concentration. Both are found mostly in green leafy and cruciferous vegetables such as broccoli, spinach, cabbage, Brussels sprouts and kale. Steaming or microwaving vegetables may also reduce loss of folate during cooking, as it is a water-soluble vitamin. Folate can also be found in fortified breakfast cereals, as with many other wholegrain foods. In future, there may be additional dietary alternatives, depending on the outcome of the ongoing open consultation33 on mandatory fortification of flour with folic acid.

CONDITIONS & DISORDERS Table 3: Portion sizes for oily fish Aim for at least one portion a week21,34

One portion of good oily fish as a source of vitamin D and zinc is roughly:

Salmon, Herring (kipper/sardines), Trout

140g (cooked weight), or 1 palm of hand One portion of good shellfish as a source35 of zinc is roughly:

Oysters, Mussels, Squid, Crab

75g or 2½oz

Although fruit and vegetables generally are not rich sources of zinc, small quantities can still be found in some.

One portion of relatively good plant as a source of zinc is roughly:

Beans, especially baked beans, but also: kidney beans / black eyed beans Pulses, such as: chickpeas / lentils

4 tablespoons (~150g)

Seeds, such as: pumpkin / sunflower Nuts

1 handful (~30g)

Nut butters, such as: peanut / almond / pine / cashew

1 tablespoon (~30g)

Folate deficiencies may exacerbate or worsen lethargy from chronic health conditions, or from poor mental health, as they are involved with bodily processes that regulate the production of haemoglobin. This is a protein found within red blood cells that is needed for circulating oxygen around our body.

Having at least five portions (one portion = 80g, or the size of a fist) throughout the day from a variety of fruit and vegetables, supports adequate intakes of naturally occurring antioxidants and fibre. These support a healthy immune system function, as a recent review28,29 of evidence from high-quality clinical trials, while conflicting, seems to suggest a potential for improvements of depression and anxiety symptoms.

PARTNER WITH PROTEIN

Tryptophan is an amino acid, a building block of protein, and is also a precursor of a neurotransmitter serotonin that plays a critical role in regulating mood. Research25-27 suggests that adequate consumption of foods from the protein food group may help with depression and anxiety.

Red meat, poultry, eggs and fish are good sources of vitamin B12 and iron, which help reduce the risk of anaemia-related tiredness.

Pairing citrus fruits or foods rich in vitamin C, and avoiding tea with meals, helps boost iron absorption.

OPT FOR OMEGA-3

Studies12,16 have shown that mood symptoms in depression and bipolar disorder may be mitigated with the inclusion of foods rich in long-chain omega-3 fatty acids, especially eicosapentaenoic acid (EPA) rather than docosahexaenoic acid (DHA).38 However, current evidence remains inconclusive and warrants further research.39 These fatty acids are mostly found in oily fish and shellfish such as oysters and some fortified eggs and milk, albeit in smaller quantities. Oily fish is also a good source of vitamin D and zinc, which, research22-24 suggests, may help with improving clinically significant mood states of anger and depression.

Although getting an adequate dietary supply of nutrients may help manage fatigue, feeling low and irritability, not all positive effects from regular consumption of specific foods are due to their nutrient content.25 HYDRATION HELPS, BUT CAREFUL WITH CAFFEINE AND ALCOHOL

Staying hydrated may help with managing low or irritable moods. Evidence shows that even a little dehydration can affect mood. The aim is for six to eight glasses (1.5 to 2 litres) of fluids every day. Water, tea, coffee, juices, milk or milky drinks, soups and yoghurt all count as fluids. The easiest and best indicator of drinking enough is a person’s urine colour,36 clear or pale yellow urine would be a sign of adequate hydration. www.NHDmag.com November 2019 - Issue 149

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CONDITIONS & DISORDERS

. . .practitioners and individuals with mental health conditions may find a validated outcomes tool such as the Individual Recovery Outcomes Counter useful during their recovery.

Some drinks contain caffeine and some individuals may feel that this exacerbates or even triggers feelings of anxiousness and physical symptoms such as palpitations and nausea.

Limiting drinks containing caffeine may help prevent this. Caffeine-containing drinks include coffee, tea, Coca-Cola, products containing cocoa and energy drinks. Alternative caffeine-free products often have ‘decaffeinated’ or ‘naturally caffeine-free’ written on the packaging.

Many people enjoy alcohol as part of unwinding from a difficult day. While the short-term positive impact on mood makes it a tempting option to turn to, alcohol has a dehydrating effect, as it indirectly stimulates kidneys to produce more urine. Current recommendations encourage limiting alcohol intake to two to three drinks on a maximum of five days each week.21 When having a drink, avoid bingeing and alternate with a glass of water to prevent dehydration.

The relaxed or mood-uplifting effect of alcohol is due to its depressant impact on the central nervous system. However, in the long run, alcohol may interfere with the neurotransmitter balances in our brain that are needed for good mental health.19 If one drinks heavily regularly, this effect of imbalance eventually exacerbates feelings of depression and anxiety and makes us more prone to aggressive behaviour.19 Excessive alcohol consumption can also lead to B vitamin deficiencies, as well as impaired memory and cognitive function. B vitamins are required by our bodies in small quantities to aid release of energy stored in glucose. B vitamin deficiencies may cause some individuals to be more prone to feeling depressed or anxious.25 42

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Figure 1: The Individual Recovery Outcomes Counter (I.ROC)

PREPARING FOR DIFFICULT DAYS

For those living with mental health difficulties, healthy eating may mean developing practical strategies to work around symptoms that may pose as challenging barriers to maintaining healthy eating habits.30 SMART (Specific, Measurable, Achievable, Realistic, Timeframe-based) goal setting may help make healthy eating a regular occurrence by problem solving. For example, having ready-prepared meals in the freezer would help prevent the missing of meals and regulate portion control.

To achieve this, a person experiencing low motivation or anxiety about leaving the house, may arrange for grocery delivery, or request assistance from friends, family, or support workers, to buy ingredients. Making the most of better days to plan and prepare nutritious meals in advance can make a difference, especially at times when limits of one’s coping skills are tested.

Some mental health practitioners and individuals with mental health conditions may find a validated outcomes tool such as the Individual Recovery Outcomes Counter30,31 useful during their recovery (see Figure 1).

But, at the end of the day, there are many ways in which nutrition can support mental health recovery, in conjunction with other psychosocial and pharmacological treatments.