An integrative nutrition approach to anxiety and depression

Photo Cred: Nutriciously/Unsplash

By Kellie Blake, RDN, LD, IFNCP

I recently had a patient who contacted me desperate for help with managing significant digestive distress after meals. She reported she loved vegetables, but had recently stopped eating them due to excessive gas, bloating, and general discomfort. After reviewing her background information, I realized she was being treated for significant anxiety and depression.

Anxiety and depression are commonplace and can contribute to poor quality of life. According to the National Institute of Mental Health, in 2017, 19 percent of U.S. adults were diagnosed with an anxiety disorder and seven percent had major depression. However, countless other Americans without a formal diagnosis struggle with anxiety and depressive symptoms.

While anxiety and depression are separate entities in the world of psychiatry, they often co-occur. As reported in the Medical Journal of Australia, an estimated 85 percent of patients with depression experience anxiety and 90 percent of patients with anxiety have symptoms of depression. As a psychiatric dietitian, I frequently see patients on medications for both disorders, but significant symptom relief is not always achieved and the medications often have unwanted side effects.

Anxiety and depression have traditionally been considered disorders of the brain, but we now understand the intimate connection between the brain and the rest of the body. In my practice, I use a variety of strategies to help patients optimize gut health and normalize their stress response to ease the symptoms of anxiety and depression.

The gut microbiome has become a hot topic in a myriad of chronic diseases including mental health disease. Alterations in the bi-directional communication via the microbiota-gut-brain axis can create and exacerbate mental health symptoms. However, this communication super highway can also be a target of integrative therapy to help patients heal.

Patients with anxiety and depression seem to have altered gut function and an altered gut microbiome when compared to healthy controls. One change, as reported in Neurotherapeutics, involves intestinal motility, which may lead to other functional and microbiome alterations like increased intestinal permeability and dysbiosis. In addition, as reported in Brain, Behavior, and Immunity, those with depression seem to have lower levels of protective bacteria and higher levels of potentially harmful bacteria.

Furthermore, alterations in the serotonergic system may also be an important consideration. Serotonin is a neurotransmitter, neuromodulator, and hormone important in the regulation of mood and emotions, but also acts to facilitate communication between the gut and the brain. Interestingly, 90 percent of serotonin is created and stored in the enterochromaffin cells of the gut. Any imbalance in the populations residing in the gut or modification to gut function can impact serotonin and thus influence mood and emotions. Repairing the gastrointestinal tract and restoring balance to the gut microbiome should be a first line therapy for patients with anxiety and depression. Addressing the stress response can also provide significant relief.

The hypothalamus-pituitary-adrenal (HPA) axis serves to help manage physical or emotional stress. People with anxiety and depression often have elevated salivary cortisol levels when compared to healthy controls, which may exacerbate mental health symptoms. Phosphatidylserine (PS), as a component of brain neuronal cell membranes, is one therapeutic option for managing cortisol levels. As reported in Mental Illness, PS is an important modulator of the HPA-axis stress response and can improve coping. When given with docosahexaenoic acid (DHA), PS appears to be effective in reducing the symptoms of anxiety and depression via the regulation of cortisol.

Case Study

McKenzie is a 27-year-old Master’s degree student who sought nutrition counseling due to worsening digestive distress. She described bloating and digestive symptoms when she ate vegetables and this seemed to be more severe than what she had experienced in the past with her irritable bowel syndrome. She said she felt nauseated all the time and wondered if nutrition-related changes would help her feel better. McKenzie also reported a lifelong history of disordered eating, initially with restricting, and then with binging and laxative abuse. While these behaviors were not active, she said she wanted to heal her relationship with food.  

She did not initially mention her depression and anxiety, but I noticed she was taking prescription medications for both (duloxetine for depression and buspirone for anxiety). During the initial appointment, she reported her symptoms of depression and anxiety started when she was fairly young and while she felt the medications were somewhat effective, she continued to have days when symptoms would be worse than others.

McKenzie is five-foot-eight and initially weighed 226 pounds. She reported frequent antibiotic use when she was younger for chronic sinusitis, but after sinus surgery, the majority of her sinus issues had resolved. McKenzie also has a history of urinary tract infections and acne. Along with her anti-depressant and anti-anxiety medications, she was taking a daily antihistamine, oral birth control, and sometimes took omega-3 fish oil, magnesium, vitamin D, and a multivitamin.

She reported craving chocolate and salty food and she was eating about 50 percent of her meals out each week. She was drinking a sugary coffee beverage and eating processed foods daily. McKenzie felt her stress was overwhelming; she was not sleeping well but was staying in bed for about 10 hours every night. She was participating in high-intensity interval training two days per week and her initial symptom score was 106 indicating severe symptoms.

The initial plan for McKenzie included:

1. A full elimination diet for four weeks to target the gut lining and gut microbiome.
2. Consume two servings of fatty fish per week to provide adequate DHA.
3. Baking soda stomach acid testing indicated adequate stomach acid.
4. Meditation for five minutes upon waking and at mid-day to target sleep and cortisol.
5. Sleep hygiene techniques, specifically in bed by 10:30 pm with a goal of eight hours of restful sleep. No blue light for one hour before bed and immediately get in bright light upon waking.
6. Supplements to include a combination supplement with ashwagandha, phosphatidylserine, l-theanine, magnolia, and epimedium to target cortisol and sleep. A multi-strain probiotic including saccharomyces boulardii to target gut health. McKenzie was to continue the prescribed vitamin D3 (5,000 units), multivitamin, and magnesium.
7. Testing to include comprehensive stool testing, salivary cortisol testing, and SIBO testing, but all were declined due to cost.

After four weeks, her symptom score had decreased to 62 and McKenzie reported much more energy. Her weight was about the same, but she felt much less gastrointestinal discomfort with bowel movements being much more regular. McKenzie said she had a difficult time eliminating corn and soy and she did have one gluten-containing meal and immediately noticed a return of her gastrointestinal symptoms. Eliminating coffee had been difficult, but she found a coffee alternative she liked. Sleep was better and she was going to bed around 11 p.m. and waking up around seven am most days. She was taking all the recommended supplements and felt they were helpful, especially for sleep quality, but she had not yet implemented the meditation.

Follow up recommendations included:

1. Continue the elimination diet for four more weeks, trying to follow as closely as possible for gut healing.
2. Meal suggestions were provided as she felt she was getting bored with meals.
3. Continue her current exercise, but implement a 10-minute walk after meals to target suspected insulin resistance, depression, and anxiety.
4. Meditation for at least three minutes per day to target stress.

After four more weeks, McKenzie said she had not been able to continue with the full elimination diet due to feeling stressed and anxious about school. She continued to be gluten-and dairy-free, but said she was eating the other eliminated foods on a daily basis and felt extra stress when trying to figure out what to eat. Her symptom score had decreased to 43 though and she was still feeling well with regard to digestive symptoms. She started seeing a therapist to address symptoms of depression and anxiety.

The follow-up plan included:

1. Focus on the gluten- and dairy-free meal plan, but continue to avoid sugar and caffeine. Monitor symptoms to try to determine specific food sensitivities.
2. Continue all recommended supplements and add N-Acetyl-Cysteine (500milligrams per day) to target mental health symptoms, detoxification, and inflammation.
3. Add in six cups of leafy greens daily to optimize fiber and magnesium intake.
4. Focus on daily sun exposure and spend time outdoors to optimize vitamin D level, but to also address depression and stress.
5. Consider acupuncture to address depression. (In one systematic review in the Journal of Clinical Medicine, acupuncture was found to be a potential adjunct in the treatment of depression).
6. Continue all other goals.

At the final follow-up, McKenzie’s symptom score had decreased overall from 106 to 18 and her anxiety and depressive symptoms were much more manageable. McKenzie said she was feeling better than she had in years and felt she had been able to add back most foods to her diet without negative symptoms.

Her long-term goals are to continue with the whole-foods diet and to eliminate any foods that cause negative symptoms. I recommended she discontinue the combination phosphatidylserine and ashwagandha supplement after six months, but to continue with the other maintenance supplements. While McKenzie remains on her prescribed medications for anxiety and depression, she reports she better understands the importance of how her gut health and cortisol levels can affect her mental health symptoms. She is hopeful for continued improvement in her symptoms of anxiety and depression and plans to work toward discontinuing the use of her prescription medications.

Resources

Armour, M. (2019) Acupuncture for Depression: A Systematic Review and Meta-Analysis. Journal of clinical medicine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31370200/

Jiang H (2015) Altered fecal microbiota composition in patients with major depressive disorder. Brain, Behavior, and Immunity. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/25882912/

Komori T. (2015) The Effects of Phosphatidylserine and Omega-3 Fatty Acid-Containing Supplement on Late Life Depression. Mental illness. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/26266022/

Sagarwala, R., Malmstrom, T., & Nasrallah, H. A. (2018) Effects of nonpharmacological therapies on anxiety and cortisol: A meta-analysis. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/29697709/

Tiller J. W. (2013) Depression and anxiety. The Medical Journal of Australia. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/25370281/