Food allergy and increased psychiatric risk

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By Wendy Pecoraro, MSN, APRN, DipACLM

In my opinion, the assumption that dietary intake and mental wellbeing are mutually exclusive is archaic. An integrative medicine approach is essential to ascertain the underlying cause of many mood disorders. For instance, more research shows that gluten elimination is an effective treatment strategy for mood and even neurologic disorders in individuals with known or unknown celiac disease, gluten allergy, or sensitivity.

In 2018, Nian-Sheng Tzeng, MD, and his colleagues from Tri-Service General Hospital in Taiwan published a retrospective study on psychiatric disorders in allergic diseases. Using data from the Taiwan National Health Insurance Program, the researchers followed 46,647 people with allergic diseases and 139,941 without allergic symptoms over 15 years. Across the duration of the study, they found a 66 percent increase in psychiatric conditions in those with allergic symptoms.

These findings are concurrent with my experience caring for many patients. Take Ellen, for instance. She is a 55-year-old married mother of four grown children who has owned and operated her own design company for many years. She presented to my office after three years of treatment with her primary care provider for insomnia, depression, anxiety, irritable bowel syndrome (IBS), and menopause.

She said her treatment led to profound fatigue in the morning followed by nervousness throughout the day that has since required her to take several anxiety medications daily. She said she had difficulty finding words and felt like she was in a fog. She reported hot flashes intermittently at least once a day. She had also gained 15 pounds in the last three years without changing her eating habits or exercise routine.

When she originally came to see me, Ellen’s diet included cereal with two cups of caffeinated coffee in the morning, a sandwich or salad at noon, and a protein, potatoes, and some sort of bread for dinner. Her preferred snack was cookies or chips, though she did not snack every day. She reported drinking at least 64 ounces of water per day. She logged regular exercise, including walking two miles five days per week and lifting weights two days per week.

Ellen’s history includes an admission to a psychiatric facility for what she calls a “nervous breakdown” after her 21-year-old nephew was killed by a drunk driver in May 2010. She has been on an antidepressant since that time. In July 2016, she had a normal screening colonoscopy and was diagnosed with IBS.

Relevant family history includes anxiety in her brother and father. Her father had colon cancer and her mother and maternal grandmother had hypothyroidism. Ellen had a significant trauma history including childhood sexual abuse, unresolved grief that involved a psychiatric hospital admission and marital problems.

Due to her continued symptoms, her primary care provider started her on an additional antidepressant two years ago. Over time, she was increased to the maximum dose of this sedating medication. These two medications did not resolve her insomnia and anxiety, so she was started on a common sleeping pill and given a benzodiazepine as needed for anxiety. Her lack of libido and marital problems were treated with testosterone injections.

Her physical exam was normal with occasional tearfulness appropriate to topic of conversation. Given her diet history heavy in grains and other processed food in addition to the ineffectiveness of her multiple prescription medications accompanied by IBS, allergies, and autoimmune disease were high on my list of differential diagnoses.

Her lab work returned with elevated lipids, particularly triglycerides at 270 mg/dL and low-density lipoprotein (LDL) was 154 mg/dL. Her anti-nuclear antibody, thyroglobulin antibody, and thyroid peroxidase antibody were normal. Vitamin D and Vitamin B12 levels were both moderately low. IgE serum allergies were strongly positive for wheat and minimally positive for walnuts and egg white.

When Ellen came to her follow-up appointment, we had several issues to address. First was the elimination of allergens and the optimization of her vitamin levels by adding Vitamin D3 with K2, 5000 international units (IUs) daily and a high-quality B-complex vitamin daily. I also asked her to add omega-3 EPA 650 milligrams/DHA 450 milligrams, two capsules daily for brain health and reduction of her LDL cholesterol. She was referred to trauma therapy for her history of childhood sexual abuse.

Ellen was open to seeing a nutritionist to help her eliminate walnuts and egg white for a month and exclude wheat from her diet. She connected with the nutritionist and saw her four times over a two-month period to give her support finding meal alternatives with those restrictions.

I saw her for follow-up after one month. She had stopped using her as needed anxiety medications after two weeks of eliminating wheat, walnuts, and eggs. She and the nutritionist were creating a plan to add back walnuts and then eggs over the next six weeks. She had minimal IBS symptoms during this time.

Ellen said she is also able to sleep soundly without medications and discontinued her sleeping pill. She stopped having hot flashes and elected not to continue testosterone injections. She said she didn’t feel like her brain was vibrating anymore.

We started slowly decreasing the first antidepression she was taking over the next month and she had no increased anxiety, depression, or difficulty sleeping. After six weeks, she was stable. She had started to slowly lose weight. She felt confident with what she had learned from the nutritionist and was able to comfortably discontinue that treatment. She had started a trusting relationship with the trauma therapist.

Next, we slowly decreased her second antidepressant to ¾ dose, then discontinued the morning dosage by half and kept her on her bedtime dosage. I consulted with the trauma therapists and with Ellen’s input, we elected to continue the bedtime dosage while they did some of the difficult psychological work.

At her six-month follow-up, Ellen was beaming. She had lost 10 pounds and her body mass index was within normal range. She has continued her therapy. Her resting heart rate had decreased from 82 to 70 and her blood pressure was down from 138/82 to 108/70. She was able to reintroduce walnuts and eggs without adverse effects, but she eats them sparingly. She had eaten gluten at special events over the last several months and felt its effects on her brain and gut. This motivated her to more diligently eliminate it.  Her B12 and Vitamin D3 levels had normalized. Her triglycerides and LDL had improved by 100 points and 40 points respectively.

This case demonstrates the importance of an integrative approach in the assessment of mood disorders. A detailed history as well as an open differential diagnosis is key to uncovering the root cause of your patient’s symptoms.

References

Eleanor Busby, Justine Bold, Lindsey Fellows and Kamran Rostami (2018). Mood Disorders and Gluten: It’s Not All in Your Mind! A Systematic Review with Meta-Analysis, Nutrients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6266949/

Nian-Sheng Tzeng, et. al. (2018). Increased Risk of Psychiatric Disorders in Allergic Diseases: A Nationwide, Population-Based, Cohort Study. Psychiatry. Retrieved from: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00133/full