Nutrition and Mental Resilience in Children and Adults: Feeding Better Health, Wellbeing and Performance
A FAB Research conference – October 2014
Introduction – Professor John Stein
The role of diet in mental resilience – an overview – Dr Alex Richardson
Nutrition and Brain Chemistry – Understanding the basics – Dr Alexis Bailey
Dietary Fats and Brain Function: Stress, Anxiety, Depression, Hostility – Captain Joe Hibbeln
Clinical Trials of Omega 3 Fatty Acids for Depression: Findings and Implications – Dr Brian Hallahan
Mothers' diets in pregnancy, maternal anxiety and depression, and children's mental health: an update from the ALSPAC study – Captain Joe Hibbeln
Nutrition and Eating Disorders – Dr Agnes Ayton
Omega 3 DHA and sleep: potential mechanisms and findings from the DOLAB study – Professor Paul Montgomery
Food, mood, anxiety and children's diets: clinical and educational perspectives – David Rex
Nutrition and Health – Are children getting a raw deal? – Neville Rigby
Professor John Stein, Emeritus Professor of Physiology, Oxford University
Professor Stein, standing in as chair for Professor Michael Crawford, pointed the audience to Professsor Crawford's seminal 1972 research which predicted that the change in human fat consumption (replacing Omega 3 DHA from fish and meat sources with Omega 6 fats from plants) would lead to a rise in cardiovascular disease (CVD) which would then plateau, to be overtaken by mental health problems.
Since 1972 mental health problems within the NHS have risen fivefold to now cost over £110 billion, more than CVD and cancer combined.
Professor Crawford would postulate that this rise is directly connected to the abandonment of humankind's 'natural' fish-based, high in Omega 3 diet and the 20-fold increase in the consumption of Omega 6 fatty acids from plant sources.
Dr Alex Richardson, Senior Research Fellow at the Centre for Evidence Based Intervention, University of Oxford. Founder Director FAB Research
Although there is now recognition that junk food is bad for the body it is not yet widely recognised that it is equally bad for the brain.
The cost of mental health care continues to soar from – £77 billion in 2007 to £105 billion in 2010 – while a 2010 European study suggested that 38% (165 million people) have a full psychological or neurological disorders (anxiety, insomnia, depression, alcohol/drug dependecy, ADHA, dementia) but that the majority of these disorders are undiagnosed.
Yet nutrition, as either a cause or a treatment, does not appear anywhere.
Very few people, even among the AB socio-economic groups, have a full range of nutrients. Indeed, many modern diets are actually pathological. Fats, vitamins and minerals, fibre and sugar are all essential for health – essential for the health of the microbiome and the gut – without which there can be no genuine health. But they are needed in the right proportions and the modern diet has become totally unbalanced, especially in relation to sugar and fats.
Excess sugar is associated with obesity, diabetes, cardiovascular disease, cancers, ADHD, depression and dementia among many other conditions. (There are strong correlations between insulin resistence and Alzhiemer's disease.)
As Professor Robert Lustig points out (see FAB conference in July), all calories are not equal and excess calories from sugar disrupt hormonal responses. Sugar, moreover, covers up the other four taste responses - salty, sour, bitter and umami. Fructose as an alternative (widely used as High Fructose Corn Syrup in the food industry, especially in the US) is actually worse as it uses a different pathway through the liver before the glucose (for energy) can be accessed.
Dose sugar make you stupid? Yes, it would appear, if sufficient is fed to Omega 3 deficient rats. Although, if the rats were not deficient in Omerga 3 fats, the excess sugar appeared to have little effect on their brain power.
The human brain is 60% fat and both Omega 3 and Omega 6 fatty acids are essential to its stucture and its functioning. However, it is the long chain Omega 3 fatty acids, AA and DHA that are particuarly important as they convert into DHA (primarily for construction) and DGLA, AA and EPA (primarily functional).
• Omega 6 fats are pro-inflammatory and pro-coagulant; Omega 3 fats are anti-inflammatory and anti-coagulant.
• DHA is neuroprotective; DHA and EPA are 'resolvins' – they help to resolve inflammation
• Endocannabinoids from both AA and EPA govern most of the receptors in the brain
In fat terms, the modern western diet is very unbalanced – far too many vegetables oils (Omega 6) as opposed to animal fats (Omega 3).
We need fish oils and seafood (Omega 3s) for neuronal membrane structure and for cell signalling - synapses.
If a mother is Omega 3 deficient there can be up to 50% fewer synapses in the developing infant brain. Maternal Omega 3 is also vital for vision development in the foetus.
There are now an increasing number of DBPCTs (Double Blind Placebo Controlled Trials) which demonstrate the importance of Omega 3 fatty acids for both the physical and mental (learning and behaviours) development of the child. See the DOLAB study and the Oxford-Durham study.
Dr Alexis Bailey, Lecturer in Neuropharmacology , University of Surrey
Food affects brain function – but how?
A failure in the frontal cortex, the decision making part of the brain, may be involved – in addiction for example. But the thalmus coordinates most autonomous activities while the amigdala controls the fear impulse. But all the regions are intimately connected and if the balance between them is disrupted, mental disorders result.
Neurons transmit information between the cells, synaptic termini regulate the levels of neurotransmitters by transporting in and out of the cells. Glial cells surround the neuronal cells; they also regulate the transmission of nutrients and destroy pathogens.
Neurotransmitters depend on glutamate, an amino acid derived from high protein foods in the diet but the cell needs to regulate the amount of glutamate released. Too much results in stroke or seizures; too little in mental health problems.
Also derived from glutamate is the inhibitory neurotransmitter, GABA which switches supply on and off as needed. Too little GABA results in anxiety; too much in a neuronal closedown.
Also essential in the mix are the monamines: noradenaline, for arousal and the regulation of blood pressure, dopamine, seratonin and acetycholine – and the opioid peptides which are mainly responisble for the feelings of pleasure and pain. Opioids also trigger rewards pathways and in obese people, the opioid receptors are decreased and the pathways disregulated. As with addicts, this means that they need to consume more to stimulate the reward system.
Captain Joe Hibbeln, Acting Chief, National Institute on Alcohol Abuse and Alcoholism, Washington DC
How seriously is the connection between dietary fats and brain function being taken in the US? And especially within the military? Well, actually, very seriously.
Significant research money is being devoted to brain nutrition to address the extremely high levels of psychological damage among the military which have resulted in more deaths from suicide in Afghanistan and Iraq than from combat. Could this be related to diet and, especially, to an imbalance in fat consumption? As Captain Hibbeln points out, 375 million years ago, there were plenty of fish – but no donuts or French fries!
In the last years of the 20th century, Omega 6 consumption overwhelmed Omega 3 going from 50% Omega 3 to 80% Omega 6. But the body is not fussy - it will use whatever is available and if that is Omega 6, when ideally it would use Omega 3, well that is what it will use.
But... Omega 6 fats produce Prostaglandin E2 (PGE2) which can go on to activate anxiety and depression while depleting dopamine receptors which, in turn, sets up for social defeat and stress and has direct influence on satiety, tolerance etc. In fact, dopamine depletion by definition creates a greater vulnerability to all neuro and neurodevelopmental problems. However, dietary EPA can reverse the immune activation of the stress axis in animals; data is not yet available for humans.
Damage to the prefrontal cortex of the brain affects its control and regulation mechanisms. (Captain Hibbeln quote the famous case of Phineas Gage, an American railroad worker who survived an accident in which a large iron rod was driven completely through his head, destroying much of his brain's prefrontal cortex and dramatically influencing his personality.) But the prefrontal cortex can also be damaged by diet.
Suicide and Omega 3
There is some, but not a great deal of historical data.
The brain should be 50/50 Omega 3 and 6 but when the diet is excessively high in Omega 6 fats, that is what will feed through to the brain. Moreover, excess alcohol and smoking will further deplete brain levels of Omega 3 fats.
If you reverse the proportion of Omega 3 and Omega 6 fats in the diet of alcoholics you can 'dry them out' in 12 weeks while there is a significant change in the composition of their spinal fluid. There was also a measurable drop in the number or drinking days among alcoholics with higher blood levels of Omega 3s.
A further 6 month trial of Omega 3 supplementation among 8–16 year-old children in Mauritius resulted in a significant reduction in aggression, especially proactive aggression (unprovoked agression as opposed to 'self defence' type aggression). Interestingly, the change in the children's behaviour also affected the parents with a comparable reduction in unprovoked aggression among the parents.
Dr Brian Hallahan, Senior Registrar in Psychiatry, National University of Galway
There are over 40 DBPCT trials on Omega 3 and Omega 6 fats but it is very hard to draw conclusions from them as there are huge differences in the criteria, the groups enrolled, the ages, the lengths of the trials and the supplements used.
From their meta analyses it would appear that:
• DHA versus placebo in depression showed no benefit
EPA does appear to reduce episodes of self harm although at a 10 year review it appeared that DHA may have been more successful over the long term.
Questions arising out of the morning's presentations
There was some disagreement over how well fatty acid supplements may be absorbed – only up to 60% or, as Captain Hibbeln suggested, up to 90%.
Although women only make up 10% of the US military, they are at 2–3 times higher a risk of depression and suicide. However, women of childbearing age are better at converting Omega 3 fats into EPA, possibly because of the need to transfer it to a developing foetus.
Side effects and sources
Combining EPA with SSRIs can reduce the side effects of the latter such as anxiety and sexual dysfunction. There appear to be no side effects to EPA supplementation.
Caucasians appear to have difficulty in converting Omega 3 fats to EPA but Africans and Afro-Americans do not, so the latter should be able to get their EPA from vegan sources. Caucasians would do better to access it from fish/animals or krill.
Algal sources of DHA are very successful but there are as yet no algal sources of EPA.
Currently it is EPA that appears to be the more important for depression and learning difficulties, but in real food both are present.
In autism/schizophrenia both Omega 3s and Omega 6s are depleted whereas in depression it is mainly Omega 3s. Autistic children on Omega 3 supplementation may become quite manic before their behaviour starts to settle and improve.
Mothers' diets in pregnancy, maternal anxiety and deprssion, and children's mental health: an update from the ALSPAC study
Captain Joe Hibbeln, Acting Chief National Institute on Alcohol Abuse and Alcoholism, Washington DC
There has always been a level of concern about the dangers of mercury ingestion from a diet high in fish but the ALSPAC study, which has been following the health of 14,500 families in Bristol from the early 1990s onwards, suggests that the impact of mercury ingestion on IQ is minimal (0.01 IQ points) whereas the impact of fish eating on IQ is very positive (5.5 IQ points). One would need to eat several kilograms of fish per day to reach mercury ingestion levels which would be toxic.
Fish consumption in pregnancy
The lowest levels of cigarette smoking were amongst the mothers with the highest levels of Omega 3s while those mothers with high levels of Omega 3s had double the chance of stopping smoking during pregnancy.
Children's substance abuse at age 15 – this was high at around 10% of the children
The families were divided into 5 diet patterns:
The mothers on the 'healthy' diet smoked less, but the really surprising finding was that the children of mothers who were vegetarian or vegan while pregnant had a significantly higher risk of substance abuse, and those who had the highest intake of soya had the highest risk of all – while those who had the highest meat intake had the lowest risk of substance abuse.
None of the usual confounding variables such as socio-economic status were relevant. So what was? Maybe an iron deficiency or a Vitamin B12 deficiency in the vegetarian mothers?
Dr Agnes Ayton, Consultant Child & Adolescent Psychiatirst, NHS Oxford
There is very little research on eating disorders and nutrition as the literature focuses on the psychological rather than the nutritional aspects. So there are many case reports but no studies.
There is much co-morbidity in eating disorders: anorexia will change into bulimia, both will co-exist with obsession.
Although there is good data on the consequences of malnutrition from the 1945 famines it focuses almost exclusively on babies, not on children or adults, and there was no follow up of psychological consequences. Today, public health attention is focused on obesity, not anorexia/malnutrition.
Many anorexia sufferers have a fat phobia and many are also vegetarian although the outcome is signifcantly worse if they are vegetarians. Long term nutritional deficiencies can cause irreversible damage.
All anorexia patients fail to meet daily requirements for most nutrients. Moreover, the data, which is nearly all self reported, is poor as consumption is almost always over estimated. So
• Thiamine deficiency can cause beriberi and heart failure and can kill
A small test of EPA on anorexics 10 years ago had very positive effects.
Bulimia and binge eating both involve high sugar foods and will interfere with insulin regulation. If the patient is also purging, they will be losing potassium which could be life threatening.
A vegetarian diet is especially dangerous for an anorexic and there is some concern as to whether anorexia may be increasing because of the current focus on healthy eating, low fat and the fear of obesity.
Professor Paul Montgomery, Centre for Evidence-based Intervention, University of Oxford.
Insomnia is a cardinal feature in depression, anxiety, post traumatic stress disorder, psychosis and eating disorders.
There are three important elements to a good night's sleep – duration, quality and timing – and there are two types of sleep: REM and NREM.
REM sleep is dreaming, 'cognitive' sleep. It is very close to wakefulness and lack of it can cause all kinds of cognitive problems.
NREM (NonRem) sleep is much deeper and is concerned with physical restoration.
A normal night's sleep will dip in and out of each type with brief moments of wakefulness but if these become too frequent or too long, they can become problematic.
Sleep can be measured in a sleep laboratory (very expensive), by actigraphy (a device strapped onto the sleeper which measures when they wake and when they sleep) and by keeping a sleep diary.
Fatty acids and sleep
Fatty acid supplementation can certainly help reduce the negative effects of sleep deprivation.
Serotonin is a key building block of the hormone melatonin which causes sleepfulness and DHA helps to increase serotonin levels.
Arachidonic acid (AA) also produces prostoglandins which help with the initiation of sleep.
The DOLAB study looked at what Omega 3 supplementation might do for 'normal' 7–9 year-olds. Blood data was taken for 400 children, 161 of whom had sleep problems. (Within that 161, the greater the sleep problems, the greater the behavioural problems. It is not uncommon for the behavioural problems in ADHD children to be caused purely by poor sleep patterns.)
In the blood samples, only 2% of the children had the maximum desirable DHA levels and the lower the DHA levels, the worse the sleep problems.
43 of the children (both 'active' and placebo) were actigraphed over a 16 week period when the 'active' children were given 600mg per day of DHA. At the end of the 16 weeks, the supplemented children were getting 46 minutes a night more sleep; the controls were getting 12 minutes a night less.
David Rex, Lead Child Health Dietitian, Highland Council
Why do children eat the way that they do? What and how they eat is affected by:
• parenting style and food culture
The gap is widening between the cost of a healthy and an unhealthy diet. Minumum wages do not cover a healthy diet and no matter how great the skills they can only partly reduce the impact of low income.
A typical diet is low fibre, high in dairy and processed meats, lacking in green vegetables and oily fish. The nutrients that will be in short supply in such a diet will all affect mood.
Irregular eating patterns are often governed by a preoccupation about body shape.
ASD and ADHD children are anxious and often have sensory difficulties. They may use food to communicate more general anxieties.
Compliance with dietary guidelines is hard and even harder when it is to do with mood and when the evidence for efficacy is slight. So drugs often favoured over food therapy.
Anxiety and food intolerance
Some foods can affect mood, but so can nutritional deficiencies. Both parents and therapists stress over dietary manipulation and there is much anxiety around food in general. Too much or too little growth, guilt over treats etc. Under-confident families are very vulnerable to 'brand pressure' and anxiety causes parents to nag. But a minimum exposure to unwanted unhealthy foods is desirable.
It is important to develop critical consumer skills in the children. Get them to look at food sponsorship, for example and then to compare the foods sponsored with those on the healthy eating plate.
Neville Rigby, Convener, International Obesity Forum
Childhood obesity levels are very high and they are related to deprivation although obesity is not exclusive to the deprived. Ethnicity is significant as it often relates to deprivation.
All children are vulnerable to pressures to consume not only through overt advertising but through subliminal advertising – on line games etc.
Self regulation in this area is nonsense. The 'Responsibility Deal' does not exist. How can a chocolate designed to look like a Brussels sprout (M&S) be 'responsible marketing'?
Since the 1990s average consumption from added sugar has been under 10% but among teenagers it averages 16%. When sugar takes up that much of the calorie total, nutrient deficiencies are kicking in. The WHO wants added sugar consumption to drop to under 5% although many experts believe that should be 2.5%. Yet the confectionery market see market growth at only 12% and children's soft drinks often contain over 60% sugar.
Nutrients in our food
Agri business has reduced the nutrients in our crops through genetic erosion of 90% of crop varieties. The homogenisation of the global diet through fewer cutlivars with higher water content has caused a decline or an imbalance in mineral and nutrient values across the spectrum.
For example, in 1980 100g of chicken had 170mg or Omega 3 fatty acids and 2400mg of Omega 6. In 2004, 100g of chicken had 25mg of Omega 3 fatty acids and 6290mg of Omega 6s. Meanwhile, Omega 3s have been totally bred out of beef.
Our food supply is significantly poorer in nutrients than it used to be so, yes, our children are definitely getting a raw deal.
Questions arising out of the afternoon session
If one buys organic food will that at least partially rectify the deficiencies?
That depends on the organic foods ... Some may but some may not. And is there enough land to feed the world organically? Possibly, but only if one were to get rid of all soya and sugar production.
Captain Hibbeln suggested that some GM and/or functional foods – soya oil bred to contain no Omega 6s for example – could be a better way to go than organic.
Should public assistance only be avaliable to those who buy healthy foods and should junk food be made VATable?
We need public support for health food choices but it is very much of a political hot potato... It would be better to improve the nutrient quality of all food rather than taxing bad food. Denmark did try a fat and sugar tax but was forced by the industry to withdraw it.
Is there a safe upper limit for Omega 3 consumption?
Research so far suggests that there are no ill effects at up to 10 grams per day. There are no figures on tolerable upper limits but look at the Inuit diet ...
Did you know that GPs can prescribe fish oil which, for children, would be free ... ?
First published October 2014
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