NUTRITION, THE GUT AND MENTAL HEALTH SCOTT SHANNON, MD FAACAP MARY - PowerPoint PPT Presentation

NUTRITION, THE GUT AND MENTAL HEALTH SCOTT SHANNON, MD FAACAP MARY RONDEAU, ND, RH(AHG)

DISCLOSURES • Dr Shannon has published two textbooks on integrative mental health and two on parenting. • Dr. Shannon is a PI/researcher on The Phase III MDMA assisted psychotherapy in PTSD study and receives support for clinical work from Multidisciplinary Association for Psychedelic Studies (MAPS), a 501c3 non profit through MAPS Public Benefit Corp • Dr. Rondeau has no conflicts 2

OVERVIEW • Diet • Population studies • Gluten • Microbiome: communication and health • Dysbiosis and disease • Physical and Mood Symptoms • Laboratory considerations • Treatment considerations

JAMA Psychiatry. 2018;75(9):918-928.

BUILD A BRAIN • Grain fortification with folic acid took effect 1/98 • Rapidly doubled folic acids levels in pregnant women • Compared MRI scans of 1,370 youths (pre/post/during) • Exposure related cortical thickness changes found • Also correlated with reductions in psychosis risk Eryilmaz H et al JAMA Psychiatry. 2018 Sep 1;75(9):918-928.

From: Association of Prenatal Exposure to Population-Wide Folic Acid Fortification With Altered Cerebral Cortex Maturation in Youths JAMA Psychiatry. 2018;75(9):918-928. doi:10.1001/jamapsychiatry.2018.1381 Date of download: 1/7/2019

NUTRITIONAL PSYCHIATRY • Consistent studies: diet quality related to risk of depression and other MH issues • Concurrently, data point to the utility of selected nutraceuticals as adjunctive treatments • New studies… are pointing to the immune system, oxidative biology, brain plasticity and the microbiome-gut-brain axis as key targets • Increased Western diet and decreased traditional diet are inversely and separately linked to MH Jacka, F EBio Medicine 2017, Mar; 17: 24–29.

POPULATION STUDIES

DIET AND PEDS MH • Systemic Review: 12 relevant studies • We found evidence of a significant, cross-sectional relationship between unhealthy dietary patterns and poorer mental health in children and adolescents. • We observed a consistent trend for the relationship between good-quality diet and better mental health and some evidence for the reverse . O’Neil, A AJ Public Health 2014 October; 104(10): e31–e42.

WE NEVER KNOW FOR SURE

DIET QUALITY & MOOD Traditional diet reduces: • Depression • Bipolar disease • Anxiety • Traditional diet includes: • High in veggies • Fruits • Whole grains • Fish • Meat • Jacka, FN Psychosomatic Medicine 2011; 73 (6): 483-90 Jacka, FN J Affective Disorder 2011; 129 (1): 332-7

ADOLESCENTS AND MENTAL HEALTH • Prospective study of 3,040 Australian youth aged 11 to 18 over 3 years • Diet quality associated with better mental health • Improving diet: improved mental health • Deteriorating diet: worse mental health • Patterns do not support reverse causality Jacka, FN PLoS 2011 ; 6 (9): e 24805.

DIET QUALITY AND PEDIATRIC MH • Prospective multi-national study of 7,675 children ages 2-9 Followed 2 years Fruit and veg intake: improved well-being Fish intake: imp self-esteem and fewer peer problems “Children’s physical and mental development is dependent on nutritional quality” Arvidsson, L BMC Public Health 2017 Dec 17(1):926

CHANGING FATTY ACID RATIO: OMEGA 6 TO OMEGA 3 n-6 fats n-3 fats • Prehistoric ~ 1900 ~ 2000 • 1:1 4:1 25:1

FATTY ACIDS AND MOOD 16 Pilot study: 38 children (11-17 yrs old) treated with emulsified omega-3. • Significant reductions in Children’s depressive inventory after 12 weeks . Trebaticka, JChild Adolesc Psychiatry Ment Health. 2017; 11: 30 Randomized, double-masked, crossover trial: 38 children. • High palmitic acid (SAD diet) vs high oleic acid diet (Med diet). • HOA group- more physically active and less angry • High fat diet (palmitate) more mood disorders and correlates positively with high serum palmitate Kien, C American J Clin Nutrition 2013 97 (4): 689

CRUCIAL FOR MEMBRANE FLUIDITY

PRACTICAL: AVOID OMEGA 6 INTAKE • However, the higher consumption of Linoleic acid, as now seen in the Western diet, shows an increase in the preference of these enzymes to metabolize n-6 PUFA, leading to AA synthesis, despite the fact that these enzymes show higher affinity for n-3 PUFA. Patterson E et al. J Nutr Metab. 2012: 539426

Decrease in Mineral Content In Vegetables Over 50 Years 100 94 86 81 78 75 Percent of 1947 Level 65 57 50 25 19 0 Ca Mg Fe Cu Na K P 1947 1997 Mayer, A B. Historical Changes in the Mineral Content of Fruit and Vegetables. British Food Journal 99(6). 1997. 207- 211.

BLOOD SUGAR • Up and down rollercoaster • High intake refined carbohydrates -->blood sugar increases--> quickly metabolized--> sharp decline in available glucose for brain = symptoms Wenzel K-G: Orthomolecular Treatment for Mental Health: The Roles of Hypoglycemia, Pyrroluria and Histamine Disturbances. 2000 Apr. Nutritional Medicine Today 29th Annual Conference. Vancouver, BC. Rao J, Oz G, Seaquist ER: Regulation of cerebral glucose metabolism. Minerva Endocrinol, 2006 Jun; 31(2): 149-158. Hoffer A: Orthomolecular Medicine for Physicians. New Canaan, CT. Keats Publishing. 1989.

FOOD SENSITIVITY SYMPTOMS • Family hx atopy • Allergic shiners • Runny nose • Hx of colic • Insomnia • Hx of eczema • Abdominal pain, IBS • Hx of reflux • Joint pain • Bad breath • Migraine/ headache • Foot odor • Congestion • Hx of otitis • Flushed cheeks/ears • Acne

ELIMINATION DIET AND ADHD • Open label phase followed by RCT crossover challenge phase • 100 children, 4-8 yrs with ADHD • Elimination diet (based on IgG) vs healthy diet • Responders challenged with high IgG foods. 63% relapsed • Conclusion: strictly supervised restricted elimination diet is a valuable instrument to assess whether ADHD is induced by food Pelsser LM et al Lancet , 2011; 5:377(9764): 494-503.

DIET AND ADHD Meta analyses: ADHD and diet • Artificial food coloring = More studies needed • Food elimination = The effect size is substantial , offering treatment opportunities in subgroups of children with ADHD PLoS One. 2017 Jan 25;12(1)p-; Diet and ADHD, Reviewing the Evidence: A Systematic Review of Meta-Analyses of Double-Blind Placebo- Controlled Trials Evaluating the Efficacy of Diet Interventions on the Behavior of Children with ADHD.

GLUTEN: FRIEND OR FOE?

GLUTEN • Celiac Disease linked to increased rates of: • CNS Disease-ataxia, dementia, vasculitis, encephalitis, epilepsy, migraine • Psych Disease-ADHD, depression, anxiety, suicide, eating d/o, schizophrenia and autism • Linked to increased risk for infertility, osteoporosis, Lupus, RLS, anemia • 30% of population genetically vulnerable: HLA DQ2 and DQ8 Cascella NG Schizophr Bull 2011 37 (1): 94-100

GLUTEN SENSITIVITY • Milder variation of CD • CD represents tip of the iceberg • Most CD is undiagnosed • As we age more convert to sensitivity or CD • Rates of CD rising rapidly? Now close to 1% • Rates of GS? 10% of population or more??? • Tests not very good for GS: Elimination diet! Ann Nutr Metab. 2015;67 Suppl 2:16-26. doi: 10.1159/000440990. Epub 2015 Nov 26. Gluten Sensitivity.

FIVE FOLD RISE IN CD • Followed 3,511 patients from 1974 to 1989 • During this 15 year period the rate of CD rose 5 fold in the followed patients • Significant percentage of adults lost gluten tolerance over 15 year period • Gluten sensitivity may be acquired and not just inherited/congenital Catassi C, Ann Medicine 2010 42 (7): 530-8.

CNS MECHANISM FOR GLUTEN? • Cerebral perfusion studied in 3 groups: CD on no diet, CD on gluten free diet and controls • CD on no diet: 73% had one or more brain regions with marked hypoperfusion • No differences between other two groups Addolorato G, Am J Medicine 2004 116 (5): 312-7.

ANTI-GLIADIN AND AUTISM • 57 children dx with Autism • Significantly higher IgG anti-gliadin than controls • No difference in celiac markers • More pronounced IgG anti-gliadin in children with GI symptoms Lau, NM PLoS One 2013. 8(6): e66155

GLIADIN ANTIBODIES AND PSYCHOSIS • Analyzed archival blood samples from newborns born 1975 to 1985. • Registry of patients with non-affective psychosis and matched controls. • Assessed for IgG antibodies to gliadin and casein. • Significance for gliadin but not for casein. Karlsson H, Am J Psychiatry 2012 169 (6): 625-32.

POSSIBLE MECHANISMS • Gut dysfunction: inflammation/malabsorption-gliadin triggers the release of zonulin (breaks down intestinal tight junctions) • CNS perfusion • Immunological shift: TH1/TH2 balance • Immunological sensitization: gliadin and autoimmunity-cross reactivity • Gliadin exorphins: partial breakdown products with CNS opiate activity • Wheat, dairy and soy contain high levels of excitotoxins: glutamic acid and aspartic acid trigger NMDA and other receptors

THE MICROBIOME

MICROBIOME • The body has approximately • 10 trillion human cells • 100 trillion bacteria • 1,000 trillion virus • Outnumber human cells 10:1 and genes 100:1

J Transl Med. 2017; 15: 73.