Malnourished Minds: The Link between Nutrition and Depression #concussion

Posted March 25th, 2012 in Concussion Nutrition, Nutrition Articles by Rebecca Lane

Reprinted with permission of Helen Papaconstantinos from www.insightfulnutrition.ca. My reason for including it here is that many of my clients with post-concussive syndrome exhibit severe depression symptoms and this information can support them.

Originally published on October 29, 2011.

Dr. James Greenblatt

Last night at the University of Toronto’s medical sciences auditorium, I attended a lecture entitled, Malnourished Minds: The Link between Nutrition and Depression, presented by Psychiatrist James M. Greenblatt, MD, based on his book, The Breakthrough Depression Solution available through the following on-line book sellers, as well as Dr. Greenblatt’s websites: http://www.comprehensivepsychiatricresources.com and http://www.jamesgreenblattmd.com.

The event was organized through the Canadian Orthomolecular Medicine Society http://www.orthomed.org/csom/csom.html and the International Schizophrenia Foundation http://www.orthomed.org/isf/isfbrochure.html .

Dr Greenblatt is a dually certified child and adult psychiatrist and pioneer in integrative medicine. He is the Founder and Medical Director of Comprehensive Psychiatric Resources (CPR), an integrative medical practice that uses a biologically-based approach to treat mental health disorder such eating disorders, anxiety and mood disorders, ADHD, and depression.

His Integrative Psychiatry approach addresses all of the factors that may incline an individual towards depression – genetics, nutrition deficiencies/excesses, and levels of stress. Where needed, he uses technology (rEEG) to ensure that medications and treatment are targeted towards individual biochemistry.  His nutrition-based approach often reduces his patient’s use of medication and minimizes drug side-effects.

By identifying and addressing all the factors that contribute to depression, his experience has been that depression can be successfully treated, and the patient is less likely to relapse. As a young psychology undergraduate, decades ago, I had worked in clinical, classroom and group-home settings with young individuals who were on psychiatric medication for various disorders.  How I wish we had this information way back then. 

Why is this topic important? Why should we care? By 2020, depression is expected to be the leading cause of disability worldwide, second only to heart disease.  And despite the dozens of antidepressants on the market, millions of people who seek treatment for depression fail to find relief from their symptoms. According to Greenblatt, standard treatment for depression successfully eliminates symptoms in only 33% of patients.  In about 70% of cases, the symptoms recur.  

Depression disrupts the lives of tens of millions of people is North America – women in particular. It is a leading cause of work disability. Each year in Canada, about 12% of the adult population has a diagnosable (i.e., clinically significant) mental disorder, with major depression being the most common. The costs – for medical care, lost work time, and loss of life – range in the region of $40 billion dollar annually, although one can never put a price on life. People who suffer from depression have much higher rates than average for various types of diseases, from heart ailments to alcoholism. Doctors estimate that as many as 8 million women and 4 million men in the United States are treated for clinical depression every year. 

But could a simple blood test change all that?

Research has shown that an over-accumulation of homocysteine, (whether due to a deficiency in folate, B12, B6, or zinc), can lead to depression.  In this way, testing for levels of homocysteine in the blood could be a very useful form of objective testing.  It is about time because depression is one of the many psychiatric disorders that lack objective testing for diagnosis and treatment.  Because of this, psychiatry is often referred to as a “measureless medicine.”    

Homocysteine is a non-protein amino acid that is quickly converted to another amino acid called cysteine. If conversion of homocysteine to cysteine is somehow impaired, homocysteine levels rise and become harmful. Too much homocysteine may increase your risk of stroke, heart disease, free radical activity, and depression.

Several important, mood associated vitamins and minerals (folate, vitamins B12 and B6, and zinc) are responsible for the conversion of homocysteine into the non-harmful cysteine.  Therefore, deficiencies in these nutrients can lead to an accumulation of homocysteine.  

So elevated homocysteine levels can indicate early stage deficiency of folate or vitamins B6 or B12 before blood levels can detect deficiency! This means that checking homocysteine levels in the body is very important if you wish to maintain health.

Not so strangely, many drugs can cause Folate Deficiency States (and therefore lead to high homocystein, inflammation and Depression). Anti-depression drugs are among them:

  • Anticonvulsants (phenytoin, primidone, Phenobarbital, carbamezepine)
  • Oral Contraceptives
  • Sulfsalazine
  • Methhotrexate
  • Triamterene
  • Pyremethamine
  • Trimethoprim
  • Alcohol
  • Antacids
  • Metformin

Amazingly, the brain knows and the gut, knows how to make its own antidepressants (for example, serotonin), given the right conditions. If that is true, what causes neurotransmitter deficiencies, dysfunction, and depression?  Integrative Psychiatry sees these anomalies as linked to many factors:

  • Genetics
  • Diet – for instance, junk food, caffeine and nicotine can lead to hypoglycaemia or not enough glucose/fuel supply to brain.
  • Stress – it was noticed that women were 2X as likely as men to be clinically depressed.
  • Neurotoxins – brain allergies, molds, fungi, yeast, candida, airborn chemicals, sugars, caffeine.
  • Inflammation – bad fats, refined sugars and carbohydrates, alcohol, cigarettes or drugs.

 Taken altogether, genes, poor diet, stress, neurotoxins and inflammation can lead not only to depression, but suppression of the immune system.

Fortunately, Dr. Greenblatt has reintroduced a biological orthomolecular framework for the understanding, treatment and prevention of Mood Disorders. He summarizes his personalized treatment approach as THE ZEEBRA approach, an easy mnemomic that covers each of the critical factors that should be addressed in the diagnosis and treatment of depression. It’s so simple that it’s elegant.

T– Take care of yourself – Getting plenty of sleep, eating right, and choosing activities that help lower stress and promote well-being are important steps to recovering from depression.

H– Hormones – Correcting hormone imbalances can often relieve depression.

E– Exclude – Exclude certain foods from the diet as problems associated with digesting these foods, such as wheat and dairy, can exacerbate depressed moods.

 

Z – Zinc and Other Minerals – Ensure adequate zinc and mineral levels; insufficient zinc is a frequent culprit in depression.

E – Essential Fatty Acids – Monitoring essential fatty acid and cholesterol levels are important to cardiovascular and mental health as low levels of these substances are often implicated in depression.

E – Exercise – Participating in exercise is known to combat depression on multiple levels.

B – B vitamins and Other Vitamins – Restoring vitamin levels to their optimal range can reduce symptoms of depression.

R – rEEG—This means ‘references EEG, which is a way of measuring brain activity much in the way an EKG might measure the activity level of your heart. If psychiatric medications are needed, rEEG can guide medication selection and eliminate trial-and-error prescribing.

A – Amino Acids and Protein

Let’s look at this again, in more detail:

Depression and THE ZEEBRA

 T – Take Care of Yourself

  • 5 Blood Tests are needed if you suffer from depression : 1) Homocystein, 2) B12 & Folate, 3)Total Cholesterol, 4) Celiac Screen, and 5) Thyroid (free T3 and T4)
    • Hundreds of studies support the relationship between folate and depression.
    • NB: Low folate is associated with increased incidence of depression.
    • With low folate, there is a poor response to antidepressant medications and higher relapse rate.
    • Celiac disease is associated with depression (2X higher rate) due to problems with nutrient absorption. (Ludvigsson JF, et al , 2007).
    • Exercise: Regular exercise may work as well as medication in improving symptoms of major depression.

 H – Hormones:

  • The brain is a cholesterol-rich organ and cholesterol is an important hormone as it is involved in the synthesis of all steroid hormones.  Don’t be afraid to eat eggs! You can have a couple a day, especially if the yolks are soft-cooked.
  • You need cholesterol for serotonin (a feel-good chemical in your brain) to work optimally.
  • Cholesterol activates oxytocin (your cuddle and bonding hormones)
  • It is needed to make bile so that you can digest fat and absorb fat-soluble vitamins such as vitamins A, D, E, and K.
  • You need cholesterol to make vitamin D, which is responsible for turning on or off many of the functions in your body.

E – Exclude:

  • Food Allergies – make an appointment with an allergist of immunologist specializing in allergies to find out what you are sensitive to so that you can avoid them and the inflammation and dietary malabsorption that allergens bring.
  • Sugar – the higher your sugar intake, the higher your blood lactate levels become.
    • Lactic Acid binds with calcium, so less of this mineral is available to keep your brain from spiralling into excitement mode.  Sugar, caffeine and alcohol all increase the lactate to pyruvate ratio in the body, resulting in anxiety.  
  • Vitamin Deficiencies – For optimal neurotransmitter synthesis, you need adequate folate, vitamin B6, vitamin B12, vitamin C, vitamin D3, and vitamin B3 (Niacin) among other nutrients.  
  • Mineral Deficiencies –A deficiency in say, magnesium, may manifest different symptoms, based on one’s own unique biochemistry and genes. In one person, a magnesium deficiency may manifest as irritability and depression, whereas in another person it may manifest as insomnia and anxiety. More on this below.
  • Amino Acid Deficiencies – Amino acids create sanity and well-being.
    • Amino Acids convert to brain neurotransmitters, which help it to function, have memory, emotions, thoughts, feelings, control depression, sleep, create energy and excitement.
    • You get amino acids from protein.
  • Heavy Metals –Vanadium toxicity can cause manic depression and melancholy.  
    • Taking high-dose vitamin C (ascorbate) reduces damage from excess vanadium. Studies in the Lancet and British J of Psychiatry show that levels of vitamin C in bipolar patients are so low as to indicate actual or borderline scurvy.
  • Toxins – these can be environmental, viral, or toxins produced in the body when you eat foods that you are allergic to.

 Ok, here’s the ZEEBRA, next:

 Z – Zinc and other minerals:

  • Zinc – depletion leads to apathy and lethargy
  • Magnesium – in terms of mood disorders, magnesium deficiency may result in depression, anxiety, irritability or depression.
  • Iron –chronic deficiency can lead to depression, weakness, listlessness, exhaustion, lack of appetite, and headaches.
  • Copper – usually a copper dominance can lead to problems. Zinc should be in a higher ratio to zinc. Watch that your house does not have copper pipes.
  • Manganese – you need it for proper use of vitamin C and all the B vitamins, and to make folic acid.
    • Manganese also helps to stabilize blood sugars and prevents hypoglycaemic mood swings.
    • Potassium – depletion is frequently associated with depression, fearfulness, and fatigue. A 1981 study found patients low in potassium were more likely to be depressed than those who were not deficient in potassium.

E – Essential Fatty Acids:

  • EPA and DHA (found in fish oils), help to lift mood and address inflammation in the body, which is also linked to depression.
  • Flax seed oil does not convert well into EPA or DHA.
  • Can get vegetarian (Algae-sourced) EPA and DHA but it is not as strong.
  • Body clues to low Omega 3:
    • Dry Skin, dandruff, frequent urination, irritability, depression, attention-deficit disorder, soft nails, allergies, lowered immunity, fatigue, lethargy, dry, unmanageable hair, excessive thirst, brittle, easily frayed nails, hyperactivity, ‘chicken-skin’ on back of arms, dry eyes, learning problems, poor wound healing, frequent infections, patches of pale skin on cheeks, cracked skin on heels or fingertips, aggressiveness.
    • Add fish to diet (especially cold-water fish like mercury and PCB-free salmon, mackerel, sardines) to diet, several times weekly.
    • Use butter and coconut oil for cooking and olive oil, flax, and borage oils for sprinkling over food.
    • Read food labels carefully and avoid all trans-fats and hydrogenated oils, including margarine.
    • Eliminate sugar – it creates inflammation and your EFAs are used up to put the fire out.
    • Take daily capsules of cold-water marine fish oil.

 E – Exercise:

  • Exercise boosts your circulation as well as your mood and production of serotonin, your ‘feel-good neurotransmitter (brain-chemical).

B- B vitamins, Folate, Vitamin D, and C:

  • Know that when you eat sugar, you are using your B-vitamins to metabolize the sugar. It is a no-win trade off. (Matthews-Larson,  PhD, Random House Pub. Group, New York, 1999, p. 158.)
  • Your emotional stability depends on a protein snack, not a Twinkie. (ibid)
  • Low B12is associated with fatigue, panic disorders, anxiety, OCD, Depression and Paranoia
    • Other symptoms of B12 deficiency include pernicious anaemia, confused mental state, tingling or numb feeling in hands and feet, sore mouth/ swollen red tongue, pallor, shortness of breath, diarrhoea, memory loss, cessation of menstruation, and fatigue.
    • Low B1 (thiamine) deficiency results in mental confusion, apathy, depression, fatigue and  increased sensitivity to noise. (ibid, p. 157)
    • Low B2 (riboflavin) deficiency causes nervous system changes and an inability to convert food into energy.(ibid)
    • B6 (pyroxidine) deficiency is the main culprit in neuropathy (needles and pins feeling) (ibid)
    • Low Folic Acid/Folate causes deterioration of the nervous system, withdrawal and irritability. It also makes it more likely that you will relapse on your anti-depression drugs.
    • Inositol has similar effects to the tranquilizer Librium. (1980s studies at Princeton Brain Bio Centre showed that brain waves were similar to those of Librium). (ibid, 157)
      • In 1996 Israeli researchers discovered that Inositol converts into a substance that regulated serotonin. (ibid, p. 158).
      • It has been used with OCD and panic disorder. At 18 grams/day it worked as well and as quickly as quickly as Serotonin Uptake Inhibitors (SSRIs) such as Prozac, and Luvox but without drug side effects.
      • Mental: Irritability, Apathy, Personality Changes, Depression, Memory Loss, Dementia, Hallucination, Violent behaviour, Anxiety
      • Physical: Diminished sense of touch and pain, clumsiness, weakness, pernicious anaemia, chronic fatigue, tremors, Gastro-Intestinal problems

r- Referenced –rEEG

Physicians report significantly reduced trial and error medication selection after using rEEG data.

Referenced-EEG is an objective, physiologically-based measure that helps psychiatrists make better prescribing decisions. rEEG measures electrical brain activity similar to the way that an EKG measures electrical activity in your heart. EEGs have been used for many years to help neurologists treat seizures and other neurological disorders. Now they are being used in psychiatry. Research has shown that although patients may have similar symptoms, they often have very different abnormalities in their EEG signal, and so would require a more individualized approach.  

A – Amino Acids and Protein

  • You need protein and fats to make the neurotransmitter ‘precursors’ that make serotonin (happiness hormone) and Norepinephrine helps to make Tyrosine (helps you focus), and Phenylalanine (helps you to feel calm).
  • BUT, you need stomach acid (hydrochloric acid) in order to break down protein properly.
  • If you are taking antacid medication, or medication for acid reflux, you can’t break down protein adequately.
  • Stomach acid  helps you to:
    • Break down protein
    • Absorb minerals
    • Absorb B12
    • Resist infection
    • Communicate to the brain that you already feel full and can stop eating (satiety)
    •  If you can break down protein, it is easier to get adequate Tryptophan, an amino acid which helps you to increase serotonin in the brain.
    • About 70% of serotonin is produced in your gut.
    • Serotonin helps make 5-HTP and Tryptophan

#Nutrition for #concussion – preliminary research results

Posted November 1st, 2011 in Concussion Nutrition by Rebecca Lane

If you know me, you know that I’m a hockey mom. The recent surge of interest in concussions in the media has started many organizations to develop protocols for getting athletes back to their game – various “return to play” rules have been written and are starting to be enforced. The OATA (Ontario Athletic Therapists Association) is also working on some protocols and asked if I might be interested in doing some research on nutrition for concussion (the # tags are for twitter.com as there is quite a group following information about #concussion for their children).

So here’s the first step in the process, writing about what I’ve found so far and outlining some of the questions I am hoping to find answers to. If you know the answers, or a great resouce where I might find the answers, to any of the questions PLEASE comment below. The more people involved, the better the results!

The following nutritional interventions were identified for review:

  1. Ketogenic Diets and/or Fasting for short periods – Ketogenic diets were originally developed in 1921 to treat epileptic children. They mimic biochemical changes associated with starvation or periods of limited food availability, and are composed of 80-90% fat, 10% protein and limited carbohydrates. In normal metabolism, carbohydrates in food are converted into glucose, which is the body’s preferred source of energy. Under some circumstances, like fasting, glucose is not available because the diet contains insufficient amounts of carbohydrates to meet metabolic needs. Consequently, fatty acid oxidation becomes favored, and the liver converts fat into fatty acids and ketone bodies that serve as an alternative fuel for brain cells. Based on the evidence presented, the ketogenic diet does hold some promise of effectiveness in improving the outcomes of TBI. There are indications that ketones may provide an alternative and readily usable energy source for the brain that might reduce its dependence on glucose metabolism, which may be impaired immediately following TBI. There is an absence of information on which forms of TBI – mild/concussion, moderate, severe, and penetrating – might benefit from such therapy. (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, pp. 140-156) (More information available in this document: Neuroprotectice and Disease-modifying effects of the ketogenic diet)
    Questions: Duration? Long-term use in pediatric population has been associated with growth retardation, kidney stones, bone fractures (p. 141) Possible intermittent timing schedule? Effects of short-term fasting? For more info about ketogenic diets, click here.
  2. Antioxidants – During a TBI, damage to the brain can occur because of the generation of reactive oxygen species (which can be offset by the use of antioxidant therapy).  Oxidative stress is identified early after the initial injury, and compounds that intercept the production of reactive oxygen species could be beneficial for TBI outcomes. The use of single antioxidants has not been successful in treating oxidative-related diseases, so only consider a combination of vitamins A, C, E, all the B vitamins along with the minerals selenium and zinc.
    (Source: Nutritional Considerations in Traumatic Brain Injury, p. 608  [also pages 88-107 of the Department of Defence document above])
    Questions: Optimal dosage? and efficacy for children?
  3. Omega 3 fatty acids – fish oils and purified omega-3 fatty acids  have been proven to reduce inflammation within hours of continuous administration. For acute cases of TBI, it should be noted that there are intravenous fish oil formulations available in Europe, but these are not approved by the FDA. Continuous enteral (a way to provide food  through a tube placed in the nose,the stomach, or the small intestine) feeding with a feeding formula containing fish oil should provide equivalent effects for this purpose in the early phase of severe TBI when enteral access becomes available. (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, p. 188-204)
    Questions: Should dosage be determined by weight, age, severity of TBI – or a combination of factors?  
  4. CDP-Choline – Choline has been shown to act as an anti-inflammatory and antioxidant in other diseases, and also to decrease calcium-mediated cell death, a feature of TBI. Choline has a critical role in neurotransmitter function because of its impact on acetycholine and dopaminergic function. Currently studies have only been done on animals, but they suggest that CDP-choline supplements increase dopamine receptor densities and can ameliorate memory impairment. It is suggested that CDP-choline may exert neuroprotective effects in an injured brain through its ability to improve phosphatidylcholine synthesis. (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, p. 115-129)
    Questions: Optimal clinical dosage and duration of treatment? Further, the DoD will be monitoring the results of the Citicoline Brain Injury Treatment (COBRIT) trial, a human experimental trial examining the effect of CDP-choline and genomic factors on cognition and functional measures in severe, moderate, and complicated mild TBI. We’ll keep our eye on results from this trial.
  5. Creatine– Creatine, which is found in meat but is common in athletes’ dietary supplements, helps give the brain an intense and immediate hit of energy needed to help cells heal right after an injury. (Source:  http://www.theglobeandmail.com/news/world/americas/starve-a-fever-feed-a-concussion-speedy-feeding-offers-hope-of-better-healing/article1994021/)
    Military personnel are using creatine in the form of dietary supplements to increase strength and muscle mass. In the context of TBI, the committee found good evidence of improvements in cognition and behaviour from trials with creatine in children and adolescents. Although this evidence comes from long-term studies, treatment with creatine was started early after injury and may have influenced disease processes during the acute phase. In fact, creatine is thought to maintain mitochondrial energetics and improve cerebral vascular function, both of which are disrupted during the acute phase of TBI.  (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, pp. 130-139)
    Questions: Timing of administration? Optimal dosage?
  6. Magnesium – Magnesium has a role in inhibiting the actions of the excitatory neurotransmitter glutamate by regulating calcium entry into the postsynaptic neuron, a process intimately related to a TBI event. Despite this seemingly neuroprotective action, there is no clear evidence that magnesium supplementation will affect TBI outcomes. (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, pp. 157-187)
  7. Polyphenols – Few studies have been conducted to test their effectiveness in TBI, however their mechanism of action in protecting against cardiovascular and neurodegenerative diseases suggests that they warrant attention as neuroprotectants. Flavonoids are able to interact with neuronal signaling pathways critical in controlling neuronal survival – specifically selected for study were cucumin and resveratrol. (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, pp. 205-226)
    Significant amounts of polyphenols – resveratrol, for example, which is found in red grapes, or curcumin, in yellow spices like turmeric – also helped keep inflammation down. (Source:  http://www.theglobeandmail.com/news/world/americas/starve-a-fever-feed-a-concussion-speedy-feeding-offers-hope-of-better-healing/article1994021/)
    Questions: Optimal dosage?
  8. Vitamin D – The role of vitamin D in the brain has only recently been recognized and is not well understood. Vitamin D and its receptor are thought to act by binding to DNA response elements that regulate gene transcription involved in cell proliferation, differentiation, and neural function in the brain. Vitamin D’s potential to increase resilience to TBI is supported by findings that vitamin D alone was also neuroprotective against animal models of stroke. Although there are only a few studies on vitamin D’s benefits for TBI treatment, the findings are promising and need to be evaluated further. (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, pp. 227-232)
    Questions: Optimal dosage?
  9. Zinc – Zinc is an essential nutrient required for the function of many enzymes in the CNS. In the brain, zinc is released in the synaptic cleft where it modulates the activity of neuroreceptors. An excessive release of zinc can result in neural cell death. In the context of TBI, zinc deficiency might exacerbate the oxidative cascade that results in cell death.  (Source: Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel, pp. 233-246) Questions: Optimal dosage?

I hope that this has given you a starting point for finding answers to your questions about nutrition for concussion. I have skimmed most of the document, but only found the pdf of the entire document available online this morning! Many of the pieces will be hidden in here no doubt.

Dosage information as well as information for children, and adult timing and efficacy need to be researched further. As soon as I have answers, I’ll let you know. But much of the research is only available for these supplements regarding other neurological diseases, especially epilepsy.

There seems to be plenty of information about ketogenic diets for brain-disorders. While I think that immediately following the TBI, the focus should be on drinking water (which I just realized I didn’t mention at all above – every source recommends “Drinking plenty of water” – but give no idea of how much “plenty” is!) and eating glucose foods, once glucose metabolism starts to break down then ketones seem like the option for brain energy. Question, when does glucose metabolism break down after a TBI?

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