TCPR: Dr. Ramsey, how did you get involved and interested in the role of diet in mental health?
Dr. Ramsey: About five years ago, I was running a day treatment program where almost everyone was obese and we were feeding patients an institutional lunch. One of our public psychiatry fellows implemented a lifestyle intervention, and that got me curious about what would be the best diet if you were looking to optimize brain health and brain function. Plus, I grew up on a farm. So my interest came from both a clinical place of seeing this as a potentially great intervention and from a personal place of always being interested in where food comes from.
TCPR: What are some healthy dietary guidelines specifically for mental health?
Dr. Ramsey: If there is one lesson that is universally true it is that people should shift to eating more whole foods, like an apple or salmon. We have moved to a diet that is focused on highly processed, packaged, convenience foods. There are two problems with this. One, we lose nutrient value; and two, we lose the experience of knowing where our food is coming from and preparing and sharing it with other people. I see a lot of benefits when patients start going to a farmers market and being social and feeling that they are contributing to their community and their food system.
TCPR: Are there specific foods that are good for our mental health?
Dr. Ramsey: We have consistent, quality data about omega-3s. The B vitamins—folate, B12, B6, and B2—all serve very fundamental functions in the methylation cycle. These can be found in leafy greens, legumes, seafood, meat, eggs, and dairy. Then there is a whole class of molecules that we don’t count traditionally, the phytonutrients, which are proving to be some of the most important molecules for health. The ones that people are familiar with are the flavonoids or the carotenoids, but there are thousands of these molecules, including quercetin and sulforaphane, which can influence liver detoxification enzymes, for example. These can be found in any whole plant ranging from onions to cacao.
TCPR: What types of mental health problems are nutritional deficiencies correlated with?
Dr. Ramsey: There are clear mental symptoms that go with a variety of major nutrient deficiencies. With pellagra [a vitamin B3 deficiency], we see irritability, dementia, and psychosis. One study showed greater than 50% of people admitted to the hospital with depression had a folate deficiency (Shavon et al, Br Med J 1980;281:1036–1038; Coppen A and Bolander-Gouille C, J Psychopharmacol 2005:19:59). Low levels of B12 lead to increased irritability and mood instability. Deficiency of vitamin E is clearly correlated with an increased risk of depression. It is a fat-soluble nutrient and one of the rules of eating for brain health is about protecting fat. Data show that more than 90% of Americans don’t eat enough vitamin E (Maras et al, J Am Diet Assoc 2004 Apr;104(4):567–575).
TCPR: What are some questions that we can ask our patients to assess the quality of their diets?
Dr. Ramsey: A one-week food journal is very useful. I ask patients to write down breakfast, lunch, dinner, snacks, alcoholic beverages, and any comments. When you look at the overall week of people’s food, you find very striking patterns. For example, you’ll see that someone just doesn’t eat any leafy greens or someone who is eating a “healthy diet” that is just very low-fat foods that aren’t very nutrient dense. You get a sense of where people are acquiring their food—if they shop and cook their own foods or rely on prepared foods—and you can help them make a better choices. When I talk to a patient about diet, I draw from the school of motivational interviewing. I try to be very nonjudgmental, and understand whether this is a place where they have motivation to make some changes, and how I might help foster that.
TCPR: What are some of the tips and strategies that you have found helpful to get patients to change their behavior?
Dr. Ramsey: I find that general tips like “eat healthier” are a waste of time. You need to be very specific with patients. In addition to the food journal, I ask patients if they have any particular food related habits such as foods that they avoid or crave. Then I give them easy steps. For example, for patients who are always in a rush and grab a slice of pizza, I suggest a nutrient-dense snack that is easy to carry in their bag, like an apple or some almonds. A lot of times, people don’t eat well because they haven’t been encouraged to or don’t know how. So I will recommend two or three healthy breakfasts that most people can eat: yogurt with some fruit or a little bit of honey; eggs and any type of vegetables you want; or a whole grain like steel cut oats.
TCPR: Are there any “superfoods” you recommend to everyone for good mental and physical health?
Dr. Ramsey: Anything that is a whole food usually has tremendous health benefits. People don’t think about an onion as a superfood, but it is a great source of quercetin and chromium. I really like to recommend kale because it is very versatile. Eggs over a bed of kale is a great meal, and you can put kale in a blender, a salad, or a sauté. I also often recommend mussels and fatty fish like anchovies.
TCPR: Are there any foods the general public is wrong about? You mentioned eggs, which often get a bad rap, or a low-fat diet that people think is healthy but is not very nutrient dense.
Dr. Ramsey: Well, telling patients to avoid fat, or that fat is bad, is really misinformation. A recent study compared a lowfat vs a low-carb diet, but if you look at the trial, the “low fat” diet gave people free rein to eat between 30% and 40% of their calories in any type of fat they wanted, and the type of fat really matters. Telling patients not to eat cholesterol has no basis in science. In general, a “healthy plate” is one with a lot of color, variety, and whole foods. Something like a skinless chicken breast isn’t particularly nutrient dense; I would prefer to see patients eating a roasted chicken instead.
TCPR: Then there are the foods that really deserve the bad rap.
Dr. Ramsey: Yes, for example, artificial sweeteners really shift the way that the brain views food by shifting your palate. So while there are not a lot of data that artificial sweeteners are horrible for your mental health, it seems that giving the brain bad information about the taste of our food or the texture of our food via industrially-created molecules is not good. One of my top rules about eating is that your food shouldn’t advertise itself. If you open a package or read an ingredient list and see, “zero trans fats!” then that food is usually a bad choice because whole foods don’t need to make any health claims and they don’t need an ingredient list. Packaged foods, fake industrial fats like trans fats or interesterified fats, artificial sweeteners, and deli meats are at the top of my list to avoid.
TCPR: When we see in the literature that the Mediterranean diet or whole food diet, for instance, cause lower risk of depression, anxiety, and other psychiatric conditions, is this simply correlation? Is it that the diets are preventative, or do people who are mentally healthy just have healthier lifestyles and eat more wisely?
Dr. Ramsey: We have to remember the study of food is fundamentally different than the study of other mental health interventions like medications and psychotherapy. This is because, by shifting dietary patterns, you are influencing thousands of things from gut flora to attitude, all with implications about brain health. Right now we can be very sure that dietary pattern is correlated to the risk of depression and likely the risk of anxiety. We don’t have causative data because we haven’t had intervention trials, although one is currently underway called “the SMILES trial” headed by Felice Jacka. A brain that is sitting in a body with high blood sugar, a mix of the wrong fats, and not a lot of B vitamins is not going to function as well or be as resilient as a brain that is in a mix of the right fats, lots of phytonutrients, and sufficient levels of vitamins and minerals. But the great thing about food is that it is a risk-free intervention that likely has huge benefits in mental health. For example, if you reduce a patient’s obesity and diabetes, you are going to improve their mental health and their risk of relapse and you are going to likely help them feel more capable and powerful.
TCPR: You write about food synergy. Can you describe what that is?
Dr. Ramsey: Put simply, a tomato, plus fresh mozzarella, olive oil, and basil is better than a tomato alone. The reason is the combination is both delicious and more satisfying, and it increases the absorption of things like fat-soluble nutrients. You absorb more lycopene and more carotenoids from the tomato because you have the fats from the olive oil and the mozzarella. Another great example of food synergy is curcumin (a substance found in the spice turmeric). There is some data that it can influence BDNF (brain derived neurotrophic factor) and be protective against dementia. And when you combine black pepper with curcumin, for example in a curry, you increase absorption of curcumin by something like two thousand percent.
TCPR: So eating well really is back to basics; what has been working for people for thousands of years still works.
Dr. Ramsey: I think almost everyone is on board that traditional, minimally processed food is the healthiest way to eat. All good diets have one thing in common; they are based on whole, minimally processed foods with a nice mix of lots of vegetables, seafood, and meat. In addition, “wild foods” give you much better bang for your buck in terms of nutrient value. For example, something like a dandelion green has significantly more nutritional value than the lettuce you find in the supermarket. Traditionally raised beef has much more beta carotene and vitamin E, and less fat, than commercially raised beef.
TCPR: Thank you, Dr. Ramsey.