 All right, thank you very much. So glad to be back here at Ancestral Health Society. I was at the very first one down in Los Angeles and met a lot of you there. So this talk is something that I present a variation to actual psychiatrists, mental health workers, other clinicians trying to help people out in the real world. So it's focused on the scientific data and real world applications. It's not gonna be as drilled down into some of the things that some of you all are interested in, but it's a way to approach people and talk to people about food and mental health in a way that pretty much everybody can understand, no matter where they come from, from a vegetarian perspective, sort of a standard American diet perspective, from a perspective that food doesn't matter to mental health, which was the perspective for a long time. So here we go. I do have a couple of blogs. I'm also on the editorial board of MedSkate, and a couple of other things I've been added since then, but none of them pay me, except the Psychology Today blog by Views. So we're gonna talk about evidence-based food and mechanisms. We're gonna skip the food assessment and then we're gonna go to a question and answer, because I only have 30 minutes. So what is the evidence that food affects the mood? Believe it or not, this is kind of a hard sell for people. And finally, in the Lancet psychiatry, not a couple of years ago, this was kind of groundbreaking. Although the determinants of mental health are complex, the emerging and compelling evidence for nutrition is a crucial factor in the high prevalence and incidence of mental disorders, suggests that diet is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterologist. I mean, can you imagine going up to a gastroenterologist and saying, I'm sorry, what you eat has nothing to do with how your gut feels, and you would be laughed out of the room. Sometimes it's actually independent, but people had that belief about psychiatry that somehow the brain is isolated from the rest of the body. And it's really hit the mainstream scientific American mind had a whole issue dedicated to food and mood. And this is why food is important to the brain. 20% of your daily calories are burned by your brain, and your brain is only about 2% to 5% of your total body weight. 60% of the glucose that you consume or make is utilized by the brain. Your brain is 60% fat. It has the highest concentrations of pufas of any organ and of any primate. It is also the largest deposit of cholesterol in the body. And they used to think, oh, it's mostly static cholesterol. So that's why they thought that statins and other cholesterol lowering medications didn't really affect the brain because it was a lot of myelin, which is it's kind of building blocks rather than stuff going in and out. But now we know that cholesterol is very important in signaling and the lipid rafts that are part of serotonin receptors and other things like that. So here we have dietary guidelines again for endocrinology, cardiology, cancer treatment. They all have their own little diet booklet and kind of mainstream ideas about how to treat these. We may or may not agree with these. Psychiatry, the American Psychiatric Association, nothing. There's no consensus document by any psychiatric organization about what you should eat or what you should even steer toward. So it wasn't, mental health is not mentioned at all in the dietary guidelines for Americans. This is shifting. They are no longer focused on the food groups. Cholesterol is no longer a nutrient of concern. There's no mention of mental health. Oops, sorry, I got lost somehow. All right, so these are the lenses that we look through when we're looking at what food. How do you build a better brain? First, nutrients and mechanisms. Second, epidemiology, the evidence that we do have in brain health. And last, sustainability and feasibility. It doesn't do any good to tell, if I'm working with a population in downtown Atlanta, to tell them to go kill and eat their own wild boars. And so let's look at the evidence. We're gonna start with the observational trials, which believe it or not, just really started rolling in in 2009. It's not even 10 years ago. All of the evidence, all of the good evidence that we have for food and mood is not even 10 years old. This was the very first study Sanchez Viegas published in one of the big psychiatry journals, archives. 10,094 people, healthy, followed for 4.4 years. If they followed a Mediterranean dietary pattern, they had a 42% decreased risk of developing depression at the end of the 4.4 years. And so this, it's kind of small, but you can see the hazard ratios at the end here. And these are the two sex tiles that are closest adhering to the Mediterranean diet. And you see the hazard ratios are between 0.6 and 0.32. So about having your risk of developing depression after four years. Just observational data, obviously. This was a study by Felice Jacka, who's one of my very favorite food and mood researchers. She's the one who did the very first study of a diet to treat major depressive disorder. We'll see that later. She did this back in 2009, right when she was first getting her PhD dissertation. And she found that teens who followed a healthy dietary pattern, again, were much less likely to develop depression. In fact, the ones with the lowest quality diet were 79% more likely to get depressed than their peers. And you saw the linear correlation there. So instead of going through all of the sort of tedious observational trials, they've did a meta-analysis of all of them. There was another new one. You guys might have seen in the news, came out in March with a big splash. It was just another observational trial. People who followed the DASH diet more closely were more likely to be less depressed. But as you can see, all of these trials, mostly Mediterranean, whole foods, more home cooking, less processed food. And there's a signal that it does decrease the risk of depression. With the little diamond at the bottom is like the combination score for all of those trials. But these are just observational, healthy people, happy people, are more likely to eat well and cook their own food and feel motivated to do that. So that may be all the signal we're seeing there, but let's try some randomized control trials to see this. So believe it or not, up until just last year or the end of, yeah, the end of 2016, the only randomized controlled trials of diets and depression used depression as a secondary endpoint or is it like a diet for a control group treating depression. So all of these studies that I'm gonna talk about right now they were usually cardiology studies because you need a lot of money for those and a lot of people wanna go on a different diet to treat their heart disease, but they happened to measure validated measures of depression or sometimes anxiety along the way. And this one was a Prety Med which also news has shown recently that they didn't carefully randomize some of their control group, but the interesting thing about it, their control group was actually like an AHA-approved low fat diet group and their research group was a Mediterranean diet and they had one where they encouraged more olive oil and one where they encouraged more nuts, all right? And what's interesting about that is you find a signal here, especially among people who, because I don't know how that's like, but especially among people who had diabetes, if they follow the Mediterranean diet, much less likely to get depression as opposed to the American Heart Association diet. And this was a randomized controlled trial where they put randomized people on two different tracks for several years. So this is actually a meta-analysis of the impact of whole food, whole of diet interventions on depression. And again, all of these were secondary endpoints for depression. They were really measuring something else, usually cardiovascular disease. And what they found, I'm trying to roll this up because I don't know the exact numbers. And I can't see on my, is there anyone, does anyone AV up here in here? Well, the exact, it shows you about what we did before and I apologize if I get the number exactly wrong, but it generally halves maybe 60%. You improve your symptoms of depression, you decrease your risk of developing depression. So this is my favorite randomized controlled trial for depression. It's not Dr. Jack as it was by Sarah Stahl. And what she did was she had elderly people at high risk for developing depression. So they did a sort of a scale for them. They found that they were all mildly depressed. Among the elderly if you're mildly depressed, you're very high risk for developing a clinical severe depression in a couple of years. And so they thought, how do we treat this in primary care? There's not enough mental health care. How do we get people to be able to do interventions? And so what they really, they were testing a therapy arm of just people giving life advice so they would have the people come in and talk to someone, listen about their problems, give practical advice. So it was like a low training. It was where people, sort of with just regular wisdom and not a whole lot of training could basically render supportive mental health care. So the other arm that they thought was the control was it where they taught people to cook and encouraged them to cook more at home. So more whole real foods at home. So and the arms were actually equal. They both prevented these people from developing depression in the next several years. But I thought that was kind of humorous that they thought they were so out of tune with even the research that was already out that they thought that a healthy dietary intervention would be a control group for depression. And this is a Dr. Jack's study. And this was a very first dietary trial to look specifically at dietary treatment of a major depressive disorder. And what they did, they had a control group that was kind of like it was a group and they were just there sort of supporting each other and talking about things. They were all had diagnosis and were being treated for major depressive disorder. Some of them were on meds, some were not, some were in therapy, some were not, but they all were randomized to the two groups. The other group was nine fairly intensive interventions. They were given a basket of food. They were encouraged to eat a Mediterranean style diet which is whole grains. But whole grains rather than processed food, less processed food, cooking your own food, lots of vegetables. And this is the difference what they did in this trial. Their Mediterranean diet did not restrict red meat because in all the observational trials, any diet that restricted red meat they failed at improving depression symptoms. And so at the end of this trial, you can see a powerful signal there. The number needed to treat, they significantly decreased depression in the diet intervention compared to the social support group. The number needed to treat for this was 4.1 which means you needed to put 4.1 people in a diet for people to have a remission in their depression. And that's about the same or less than many chemical antidepressants that we have. It's statins the number needed to treat and it's a different endpoint for to reduce death as something like one in 100 or two in 100 depending on the population. So this is just something I throw in there. Another diet and behavior intervention. If you go to the Cleveland Zoo and look up Gorillaz beat disease with diet, there's a two and a half minute video. These Gorillaz were picking at themselves and ruminating. They would eat their Gorilla pellets, throw them back up, eat them again, throw them back up, eat them again and they were tearing their hair out. And so they decided to put these Gorillaz on an ancestral diet. Gorillaz eat 11 hours of the day. They have huge long guts. And so they give them a lot of Romaine lettuce and took away their Gorilla biscuits. And these behaviors, it was actually to help their heart disease. Same, because one of the Gorillaz had died of a heart attack. But these Gorillaz got a lot better and they're all, they're ruminating and they're picking behaviors went away. So they were no longer anxious. And so this is just a little trial I'll mention, I think from Belgium, Inca study. And they put, it's a weird diet. They put them on an elimination diet as they thought ADHD might be caused by food allergies. But it was rice, turkey, lamb, vegetable fruits. Sorry, margarine and vegetable oil. Tea, pear juice and water. It was a crossover trial. And 78% of the children showed improvement as opposed to sort of a processed food diet. Again, I wouldn't have chosen this diet, but that's what they picked. So what are the mechanisms? There's nutrient deficiency, insufficiency, neuroplasticity in BDNF. BDNF is brain-derived neurotrophic factor or like, I like to call it brain fertilizer. And it tends to drop in depression. And all of our chemical interventions in depression, yoga, therapy, those things tend to be associated with increases in BDNF in the plasma and in the brain. So basically what our treatments for depression do is increase brain fertilizer to help you recover and repair from stress. That's the way out view. So what is neuroinflammation? It's a very hot area of mental health and research. And how do we kind of go back there? Here is sort of a complicated slide about different ways that you influence neuroinflammation. And so you get stress leading to cortisol being produced, kind of over-activates the brain and the sympathetic nervous system. The fight or flight nervous system gets overactive. And then the rest and digest nervous system is underactive. So all of our interventions are about getting the more imbalanced. And gut dysbiosis is actually a big part of this. I'll go into that later. And this was back to that prety med intervention. Oh, nevermind, this is a different one. So this one, they showed that this inflammatory diet, you had much higher measures of inflammation in the blood. That was the inflammatory part. I know they had meat over there. And then I'm gonna talk more about meat versus meat later on. And these were the elements of the anti-inflammatory pieces of the diet. And this was just interesting. It's a kind of a complicated slide, but it showed that people who followed people over time in their inflammatory markers, and if they ate a healthy diet, it not only protected them from depression, but it affected, if they were under tremendous stress, their inflammatory markers didn't go as high if they were on a healthy diet. This is another Felice Jacka study. She measured the hippocampus of people, I think 62 to 69 over a period of, again, like five to seven years. And as you can see, everybody's hippocampus shrinks over time as we get older. It's a part of the brain that affects memory and stuff like that. But the people on a healthy dietary pattern, their hippocampus shrinks less. And you start out much smaller if you have a poor diet. And so now at the microbiome, there was Anton von Leewenhoek, who first scraped his tooth and looked under his microscope and saw little living antimicules, very prettily and moving. And you guys all know all this stuff, but there's an intersection between a bi-director communication between the gut and the brain. So if you take a mouse away from its mother, the gut flora is altered. Stress and sleep will affect the human gut flora. There's increased translocation of gram-negative bacteria, talk to bacteria, and increased LPS, which is a measure of bacterial contamination of your blood in patients with major depressive disorder. And these are all the different bacteria. They actually produce our own neurotransmitters. And through mouse studies, we know that the bacteria can affect your behavior, kind of creepy. So they're talking to you through the vagus nerve. And so different bacteria can make you have a different mood or response to things or change your resiliency. So if you're thinking about a fecal transplant, there's a lot we don't know. I'm not really a DIY fecal transplant advocate myself, but you wanna make sure it's from a pretty serene person, okay? And this is just how the gut bacteria affect the brain. Again, it latches on to that sympathetic versus parasympathetic, fight or flight versus arrest and digest nervous system. And pathogenic bacteria in your gut will activate that fight or flight nervous system. It's another stressor that your body has to deal with. And things like probiotics can intervene in that cascade. The things that we have, if you look at this cascade, if any of you are psychiatrists or family doctors or OBGYNs, whoever uses stuff like an SSRI, we're affecting serotonin up there on the brain side, sometimes more successfully than others. But probiotics actually affect the same process and increase healthy signaling of serotonin on the gut side with a lot fewer side effects. Not as strong of a signal as SSRI signal, but that is the future of what they call psychobiotics, which I also think would make a good band name. And this is just studying the microbiome. This is from a study where they took African American men and they put them on a traditional South African diet. This is by O'Keeffe, who is well known for his hatred of red meat and TMAO. But this is an interesting study. This is just to show the kind of data that you get from a microbiome study. So you kind of need a supercomputer to figure it out. So tell me, after switching African Americans to a traditional South African diet for two weeks, the healthy butyrate producing microbial species in the gut increased by... So butyrate is the short fatty acids in butter. And so if you have the right bacteria, when you eat fiber, they change it into not exactly butter, but close enough. So we all think that's good, right? You make your high fiber diet into a high fat diet. So it's 250%, two weeks. All right, and so there's a bunch of other kind of studies linking just changes in the microbiome to different mental health. There was a recent one with schizophrenia. There was another one that showed mania. It was really just two weeks ago. I'm gonna blog about it, but I haven't yet. And this is how, in more detail, if you wanna write all that down, exactly how you get from the microbiota up to the brain and all the different intervening things. This is from a, yeah, it's from Wang et al in brain behavior and immunity in 2014. It's actually open access and it's awesome. It's kind of a really good primer for this kind of thing. Wang et al in brain behavior and immunity 2014. So when you ask people as a clinician, do you eat a healthy diet? Oh, sure. What they mean is they count calories, they avoid cholesterol, they avoid fat, and they don't eat red meat. But they drink a lot of red wine, right? This was in 2009. I know I've heard recently, we don't need vitamins because most of us get our vitamins. Well, this is the percentage of the U.S. population not meeting the RDA. And look at these really important brain minerals. Zinc, magnesium, B vitamins, vitamin B12, 30%. And your brain cannot operate without vitamin B12. And this is one of the reasons why. So in 12 to 19-year-old boys, they get 273 of their daily calories from soda. I'm just gonna skip through that because you already know that. So inadequate intake of vitamins and minerals is most common among. Sorry, I should have stopped and asked you. So, oops. These are the most important minerals for the brain. Long chain omega-3s, folates, fiber, that's again to build happy, healthy microbiota that's associated with happy, healthier things. But I think we have some different ideas about that. In this group, vitamin B12, vitamin D, thiamine, magnesium, calcium, vitamin E, choline, iron and zinc. And a lot of these, B12, iron, zinc, choline, long chain omega-3s, the best sources are animal foods. And if you go entirely vegan after not too many years, you will die of vitamin B12 deficiency. So these are sources of these good brain foods. If you wanna eat well for your brain, over there are oysters, kind of, or clams. Iron, so iron is the most common mineral deficiency in the world, especially among women. I know a lot of men worry about iron overload, but from a public health perspective, iron deficiency is more common. So you can get it from clams, you can get it from up at the top. Anybody know what that one is? Yes, liver, yummy, delicious liver. The bottom one, you know what that one is? Cashews, yeah, so a 6.1 milligram serving will give you 34% of your iron you need daily. And then pumpkin seeds over there. And y'all know what this is? Yeah, dark chocolate, 17 milligrams will give you 97% of your iron, did you know that? So this is what psychiatrists do a lot of the time. We block all the receptors and we try to get things much normal, but I like the pharmacy. At least to augment my pharmacy, I have a lot of pretty sick people who need medications, but I try to limit those medications as much as possible and get them back to functioning and eating well. And this is my friend Drew Ramsey's brain food prescription. Really focuses on more, you know, seafood and vegetables. He used to be a vegetarian, so he's not as pro red meat as I am, but he has some helpful swaps for people, like a salmon burger for a fried fish sandwich, dark chocolate almonds for white chocolate pretzels, that kind of stuff. And he loves seafood, because again, they're just a powerhouse, especially oysters and mussels for brain nutrients. So you're zinc, you're long chain. Omega-3 is your B12 and your iron. It's all there. This is some more stuff on Omega-3. It's good for your brain. It's good in pregnancy. He loves kale. He wrote a book called 50 Shades of Kale. It's a recipe book. It's really funny. It's good. And then he also eat a lot of rainbow of foods. And this is sort of my, I like vegetables. I'm not really a carnivore myself, but I think Michael Pollan in his very first book made a good point that humans used to eat hundreds of different species of vegetables all the time, and we kind of were down to lettuce and broccoli and peas. And so eating the different rainbow of foods can help you get a smattering of the different phytochemicals for hormesis, right? And he's a big nut fan. And so this was the interesting, this was the prety med Mediterranean diet plus nuts. It increased your plasma BDNF. So you're at much less risk of having low plasma BDNF, which is that brain derived neurotrophic factor. So I thought that was interesting. And look at the Mediterranean diet plus olive oil, no protection. It was the nuts. Isn't that interesting? Again, it's observational, but fascinating. All right, beans and legumes and then grains. So if you're talking public health, a lot of people, again, they're pro Mediterranean diet, but I have this slide in here to say there's more to grains than wheat and all sorts of different things that you can try. But I just wanna put this in. What about gluten and mental health? There's some very interesting signals. The biggest trial of the treatment of schizophrenia in the United States was called the KD trial. They happened to measure along the way markers for celiac disease, which I thought was very sensible of them. 23% of the patients with schizophrenia had the IGA marker for celiac disease versus 2.3% of the general population. That's a pretty wild signal, right? And if you have celiac, you're more likely to have schizophrenia. If you have schizophrenia, you're more likely to have celiac. And I think it's a sort of an inflammatory autoimmune marker. And this is just how celiac works. It bursts those tight junctions open. So then you have your poo in your blood, as Rob Wolf would say, which is not good. This is actually a patient of mine who made the New England Journal of Medicine. She's a 37-year-old woman with no previous psychiatric history, no family history, and suddenly became completely delusional and psychotic. She told me that the ravens or birds fighting outside her doorway were actually computer robots built to spy on her and to make her upset because she was a vegetarian and she didn't like birds hurting each other. Nothing worked, no medicines worked. She had celiac disease. When she first showed up, they finally were able to hospitalize her because she was so delusional and she weighed like 95 pounds. She was very low in B12. It took them a little while and Hashimoto's thyroiditis for them to figure out that she also had celiac disease. When they treat her celiac disease, her delusions went away entirely. She relapsed a couple of years ago and when I checked her, she cheated on her diet. She'd eaten some Chinese food. And after that, she was again psychotic for about a year before we got her back in line. Finally figured out in medication that worked with her but in which she stays on at a low dose but she's also very much careful to be gluten-free now. And then meat and eggs, lots of nutrition there. This is a Kefo. This is not the meat that we like. This is my family farm. This is the kind of meat that we like. We just raised cows there in the summertime to fatten up on the nice green grass there. And then meat and vegetables. And again, this is the kind of meat I'm not talking about so much, especially that stuff on the right there, kind of gross. Eggs are fantastic for you. Very interesting study about choline and risk of brain aberrations that predispose you to schizophrenia later in life. Give a pregnant mom enough choline. Their babies don't have the problem. So can you eat to build a better brain? I say yes, you do. Colors, fats, flavor and fun. Don't be scared of fish. Remember clams, you can sneak that into a pizza and other things. Whole foods or Mediterranean diet pattern are scientifically shown to be productive for depression but also dementia, anxiety, bipolar and ADHD. And learn from history, put the genie back in the bottle. Processed foods just aren't very good for you. They'll keep you alive. They'll give you 500 kids but they're not that good for you. So this says, of course you feel great, these things are loaded with anti-depressants. All right, any questions? Thank you. Hi, that was a great talk. I'm just curious, based on this research that's coming out or any of the mental hospitals or places like that latching onto this and trying to change what they're actually feeding the patients there. It really depends on the hospital. I know when I was at the Physicians for Ancestral Health Conference a while back, there was a psychiatrist working in kind of the inner city. I'm gonna say down in Tennessee, Nashville maybe. And he was able to have some influence to take away some of the processed food. But institutional food, weirdly you think it would be the easiest stuff to change because you have absolute control over what they're eating. But it's some of the hardest because it's not cheap. One thing though about the Mediterranean diet, Felice Jacka's study where she put people on a diet, she calculated economically and asked them what they were spending on their weekly food before they started the diet and then after. It actually went from $138 a week, that's Australian dollars, down to $112 a week on their fresh food diet. So they were saving money. I think more analysis like that would really help this go forward. And economic analysis is part of these, any of these interventions for cardiology, for mental health, anything. So if you are a researcher, tell me about the money, okay? Hi, Emily, thank you. How has depression quantified? What if people have legitimate reasons to be depressed and then, oh, we're going to change the diet and you're less depressed, but doesn't that bring about like a false sense of reality, like how do you do it in your field? Am I really talking just a clinical depression? There's absolutely nothing wrong by, let's say, I tried out for the orchestra and I failed, I didn't make it, for me to be down after that. That's totally normal, that's not pathologic at night. If you're not down after that, there's something wrong with you. So I'm talking about a clinical depression which is defined as multiple issues, suicidality, inability to function, foggy brain, lack of energy, lack of motivation, you know, sad most of the time and it has to last for at least two weeks for a major depressive disorder. It's significantly debilitating and about 6.2% of us meet that criteria at any given time. It's also distinguished from bereavement which is probably the most likely reason you're gonna feel super depressed and there tends to, again, to be lots of feelings of guilt and suicidality. So wanting to end your life. And so it's that, that is very different from feeling down, there's nothing, we need to feel down. We need to feel bereaved when we lose our loved ones. There's nothing wrong with feeling sad, but if you're sad for too long or you're overstressed, that's because that hypothalamic pituitary adrenal system is overloaded with stress and cortisol on your brain and it's associated with inflammatory cytokines and inflammation. Your immune system in your brain is overactive and it actually causes the cells not to work, not to regenerate the communication to break down. So it's an actual pathologic condition. And that can be measured? Yes, well they usually measure it, sometimes they measure it with cytokines and often they measure it with the rating scales and most of your rating scales will specify at least two weeks and they will have all of those different, some of their pain aspects, so people who are depressed feel pain more and those different rating scales have all that. You have to meet the established criteria because we don't wanna overdiagnose people with depression. That's just as bad as not treating it.