If you have received a mental health diagnosis have you first had the role of your nutritional status checked? The diagnostic and statistical manual of mental disorders (DSM-5, 2013) is the most current edition of the guidebook for psychiatrists and psychologists who follow a diagnostic framework. Within this book are over 300 classifications for various 'disorders' (e.g., major depression, generalised anxiety disorder, panic disorder), that are determined by an individual meeting a certain number of symptoms, to a certain level of severity, over a certain period of time. This manual has built in caveats which are called rule-outs. These include external factors that are known to produce psychological symptoms for some individuals. Those trained in using DSM-5 learn a process of differential diagnosis, which considers several possible alternative explanations for symptoms (rule-outs), before making a formal diagnosis and recommendations for treatment.

Examples of rule-outs are substance-induced or medication-induced mood, anxiety, psychotic, or other disorders. When a substance is suspected to be causing symptoms, a period of abstinence from it is recommended, and symptoms monitored to see whether resolution of symptoms occurs. A common example of this is alcohol. For some individuals, alcohol use will cause or exacerbate low mood (i.e., alcohol-induced depression). Caffeine or sugar are also substances which may cause anxiety or panic attacks in sensitive individuals. The mere absence of the substance in these cases may lift mood or reduce anxiety, while reintroduction will again bring about symptoms. The good thing about this is that people then always know they have a choice (i.e., if I use X substance then I accept Y consequence).

Other examples of rule-outs involve biological factors or health problems that may masquerade, in part, as psychological in nature. Common health conditions that can do this are thyroid, sex hormone or HPA axis dysregulation. Unfortunately, sometimes these underlying explanations for symptoms get overlooked - and haven't been ruled-out or factored into the picture. One frequently overlooked rule-out or contributing factor in psychological presentations is that of nutritional inadequacy or deficiency, such as Iron or Folate deficiency. This is kind of amazing, as I have learnt that the very earliest signs of a nutritional problem are usually psychological (e.g., anxiety, fatigue, cognitive impairment, low mood, and insomnia). Therefore it makes sense that people might seek psychological assistance, or see their GP, to enquire about anxiety or mood treatment options for what could be a nutritional problem.

Nutritional deficiencies 

Why are nutritional inadequacies/deficiencies so often overlooked as a factor in mental health symptoms? Sometimes these are not tested at all through simple screening blood tests, but other times it seems because optimal levels (required for feeling your best) differ from what are considered a deficiency according to conventional blood test reference ranges. Additionally, there has historically been a lack of nutritional training within both mental health and medical training programmes, and many practitioners may not focus on this or feel equiped to include it in their work. New Zealander's experience suboptimal nutrition or deficiencies for a variety of reasons. Those at greatest risk are reported to include the following populations - people with chronic illnesses (IBS, chronic fatigue, autoimmune conditions), those taking multiple medications, the elderly, sedentary populations, pregnant and breastfeeding women, vegans/vegetarians, some athletes, those using alcohol and other drugs, and those who are socially isolated (Kotsirilos, Vitetta, & Sali, 2011). 

Nutrient dense foods with adequate vitamins and minerals are foundational in both the structure and function of the brain. Research has found that both adults and adolescents eating a diet higher in healthy fats and protein, fruits, vegetables, nuts, and seeds have lower rates of anxiety and mood difficulties (Davison & Kaplan, 2012; Jacka, et al., 2011).

Reasons for nutritional deficiency to occur can include:

1. Poor nutrient intake because the diet lacks adequate nutritional content for that person's needs (e.g, insufficient diet, veganism or vegetarianism, poor soil conditions, ultra-processed/sprayed foods)

2. Good intake of quality food but poor digestion or absorption (e.g., gut health issues; low stomach acid)

3. Interference with absorption because of 3rd party interference (e.g, tea, coffee, alcohol, gluten, or medications interfering with absorption)

4. Inability to absorb well due to chronic stress, anxiety, or unprocessed trauma. This is explained in part by the Triage Theory of nutrition where the body will prioritise nutrients to organs involved the fight-or-flight system

5. There are also less optimal genetic variations that mean some people may need higher levels of certain nutrients than others.

Particular nutrient insufficiencies that can wreck havoc with mood, anxiety, and energy reserves, as well as cognitive functioning (e.g., memory and concentration), include Vitamin B12 (only available from animal products), broad spectrum B Vitamins, Iron, Vitamin C and D, essential fatty acids (EPA, DHA), amino acids, and the minerals magnesium, selenium and zinc. Nutrients work synergistically (together) and so in reality the brain needs all of them (about 30!), every minute of every day and inadequacy in one area may have a domino effect and impact in other areas (Kaplan & Rucklidge, 2021).

Spotlight on Vitamin B12

One common issue I see a lot in my practice is low Vitamin B12, which can present as anxiety or panic attacks, chronic fatigue, memory impairment, low mood, or even neurological symptoms (e.g., numbness and tingling in your arms or legs). Long-term problems associated with this deficiency are as extreme as dementia and pernicious anemia (risking brain, stomach, and nerve damage). Thus, B12 deficiency can become severe and debilitating. Currently there is no universally accepted reference range or clinical cut-off that determines a deficiency using a blood test, which is a rough method of detecting deficiency. Additionally, ranges used in New Zealand are often lower than what research findings and clinical experience suggest are required for optimal functioning.

In New Zealand, unless a persons blood results are below around 180 pg/ml they are rarely offered B12 treatment (intramuscular injections or sublingual tabs) in my experience. Yet research finds symptomatic people who score well above 180 pg/ml, and in Japan and Europe those under 500-550 pg/ml will be treated (Dharmarajan, Adiga, & Norkus, 2003; Hannibal et al., 2016; Lachner, Steinle, & Regenold, 2012). When deficiency has been detected (and in my experience, the more generous range of 550 pg/ml should be used if someone is symptomatic) then a B12 tablet (e.g., 1000 mcg -1mg- of sublingual methylcobalamin) is suggested, as well as a root cause analysis to understand what is causing the problem. This part is important so that malnutrition or malabsorption can be rectified through diet and lifestyle interventions, or ongoing supplementation - particularly this is necessary for anyone not including animal products in their diet. In my practice these days I generally recommend a full broad spectrum B vitamin over a B12 only approach as the whole suite of B vitamins work synergistically with B12. Additional sublingual B12 or injections helps if there are gut absorption issues or the level needs to be boosted up quickly. I also support people to discover the food sources of B12 (e.g, eggs, red meat, dairy) and educate that if they are not eating any animal products they won’t get any B12 period, and the only option is to supplement.

Nutritional interventions for mental health:

1. Education and the provision of relevant resources and research around nutrition and the gut-brain axis

2. Blood tests for relevant tests via the GP (e.g, B12, Iron)

3. Advice and behavioural change interventions to maximise nutritional intake (e.g., dietary modification or supplementation)

4. Interventions that help with gut digestion and absorption (e.g., reducing caffeine and alcohol, working with a GP, gastroenterologist, or an adjunctive nutrition experts to assess and heal the gut)

5. Enhancing the bodies ability to get into the “rest and digest” relaxation response to digest/absorb optimally.

This can include all the traditional and well researched psychological therapies such as motivational work, mindfulness skills, relaxation, addressing trauma, sleep hygiene, improving interpersonal relationships and connection, and lifestyle modifications.

This article put a spotlight on micronutrients (vitamins and minerals) as a possible causal or contributing factor in common psychological presentations, including anxiety, mood or cognitive difficulties. The work of Professor Julia Rucklidge and her colleagues provides a growing evidence-base for nutrition as an effective alternative or adjunctive approach to therapy or medication for people experiencing mental health difficulties. There is much work to be continued in understanding how best to use nutritional interventions within a mental health scope of practice. In saying this though, the research base to date is sufficient to conclude:

"Nutritional medicine should now be considered as a mainstream element of psychiatric practice, with research, education, policy, and health promotion supporting this new framework"

(Sarris, et al., 2015).

For anyone wanting to explore this area further check out the TedX talk by Professor Rucklidge and her new book - The Better Brain. 

If you would like to find out more about the role of nutrition in your experience of anxiety or overwhelm check out the new course I have co-created with my Naturopathic colleague Felicity Leahy. This course guides you through our self-assessment process to figure out and resolve any nutritional culprits in your own mental health experience.

Be Your Own Health Detective: Alleviate Anxiety or Overwhelm With Nutrition is now open for enrolments. We look forward to helping you on your journey to more revived mental health!

References

1. Davison, L.M., & Kaplan, B.J. (2012). Nutrient intakes are correlated with overall psychiatric functioning in adults with mood disorders. Canadian Journal of Psychiatry, 57, 85-92. 

2. Dharmarajan, T. S., Adiga, G. U., & Norkus, E. P. (2003). Vitamin B12 deficiency. Recognizing subtle symptoms in older adults. Geriatrics, 58(3), 30-4.

3. Jacka, F.N., Kremer, P.J., Berk, M., de Silva-Sangigorski, A.., Moodie, M., Leslie, E.R., ...Swinburn, B.A. (2011). A prospective study of diet quality and mental health of adolescents. PLoS ONE, 6(9), e24805.

4. Jacka, F. N., Cherbuin, N., Anstey, K. J., Sachdev, P., & Butterworth, P. (2015). Western diet is associated with a smaller hippocampus: a longitudinal investigation. BMC medicine, 13(1), 1.

5. Kaplan, B. & Ruckildge, J. (2021). The Better Brain: How Nutrition Will Help you Overcome Anxiety, Depression, ADHD and Stress. Random House, UK.

6. Hannibal, L., Lysne, V., Bjørke-Monsen, A. L., Behringer, S., Grünert, S. C., Spiekerkoetter, U., ... & Blom, H. J. (2016). Biomarkers and algorithms for the diagnosis of vitamin B12 deficiency. Frontiers in Molecular Biosciences, 3, 27.

7. Kotsirilos, V., Vitetta, L., & Sali, A. (2011). A guide to evidence-based integrative and complementary medicine. Elsevier Australia.

8. Lachner, C., Steinle, N. I., & Regenold, W. T. (2012). The neuropsychiatry of vitamin B12 deficiency in elderly patients. The Journal of neuropsychiatry and clinical neurosciences, 24(1), 5-15.

9. Sarris, J., Logan, A. C., Akbaraly, T. N., Amminger, G. P., Balanzá-Martínez, V., Freeman, M. P., ... & Nanri, A. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet Psychiatry, 2(3), 271-274.

10. World Health Organisation (2008). Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food and Nutrition Bulletin, vol 29, no. 2 (supplement), S238-S246.