Getting enough protein as a vegetarian or vegan

This video talks about how vegetarians and vegans can get enough protein and be at their best.

• 0:00 Intro

• 0:21 How much protein do I need? (here’s a link to the Huberman Lab podcast referenced)

• 1:39 Challenges with getting enough protein

• 4:43 Sources of protein

• 6:37 Protein powders

• 7:10 Sample menu

• 8:22 Glucose curves with different types of food

• 9:16 Continuous Glucose Monitors as a tool

We're working on creating short educational videos this year and would love your feedback and topic suggestions!

Continuous Glucose Monitors and Mood

This video talks about how glucose levels impact mood, focus, and fatigue - and shows an example of what hypoglycemia looks like on a continuous glucose monitor. Learn more at KristenAllott.com

We're working on short videos this year and would love your feedback and suggestions for topics!

Suicidal Behaviors Linked to Steroid Treatments

The research study that I am highlighting this month is especially for mental health professionals who follow my newsletters.  It may explain in part why your patients may do very well and then suddenly they are more depressed or suicidal.  The summary, which follows, discusses how glucocorticoid (steroid) therapy can increase depression and suicidal ideation in your clients.

Most commonly, I have seen Prednisone prescribed for bronchitis or asthma.  Sometimes steroids are also used for acute flare-ups of autoimmune diseases such as MS.  Although the research did not specifically look at local injections of steroids for joint pain, I have seen a few patients in my office struggling with depression and the deepening of the depression within the three-month window of steroid injection(s) for knee pain.

Let me state again: I am not against the use of medications.  I simply want people to know that they may experience depression or suicidal behaviors as a side effect of this medication.  If they wait it out, those side effects will go away.

In a United Kingdom study over a period of 18 years, researchers assessed 372,000 adult patients who received prescriptions for oral glucocorticoid compared with those patients who did not receive such prescriptions.  This is the largest study to date examining the effects of glucocorticoid treatment on adverse neuropsychiatric outcomes.

Simply put: Glucocorticoids increase the risk of suicidal behavior and neuropsychiatric disorders.

Authors Fardet, Petersen, and Nazareth reported “finding a high incidence of neuropsychiatric adverse events in the first 3 months of treatment with glucocorticoids.  Over all, the incidence was 15.7 per 100 person-years at risk.  For patients on their first course of glucocorticoids, it was 22.2 per 100 person-years at risk.  Older men were at higher risk of delirium, confusion, disorientation, and mania, while younger patients were at higher risk of suicide or suicide attempt.  Patients with previous histories of neuropsychiatric disorders and those treated with higher dosages of glucocorticoids were at greater risk for neuropsychiatric outcomes.”

These research findings should give us all pause.  Physicians must exercise caution in administering these drugs.  All of us have monitoring responsibilities.  Information and education for patients and their families are very important in order to eliminate, as much as is possible, adverse reactions and misinterpretations of side effects.

Get Rid of Icky-Fishy smelling Omega 3 Pills

Most people have heard that fish oil is “good for you”. Yes, it does help with depression, bipolar, ADHD, cardiovascular disease, diabetes, obesity, and dementia. This appears to be scientifically true.  It is so good for us that the company GlaxoSmithKline has convinced the FDA to approve an omega 3 medication called Lovaza for treating high cholesterol, triglycerides, cardiovascular disease, and diabetes.

My concern about omega-3 products centers on the fact that not all fish oils are created equal.  What accounts for the differences?  In a word, it is QUALITY.

Many of my patients come to my office already taking a fish oil product that they picked up at their favorite discount grocery or supplement store.  I can see medically, it is not working.  I ask my new patient: “Have any of the following improved with the use of the omega 3 you are now taking: skin dryness, joint discomfort, mental clarity?  Have your triglyceride scores decreased?  (Healthy scores are below 80.)  Have your HDL scores increased? (Good cholesterol ranges are 50-60.)  Almost always, the answer is “No”.

When I switch the patient over to what I consider a quality omega 3 product and that product is kept in the refrigerator or freezer as I have instructed, my patient’s over all-skin condition, as well as moods, improve.  In addition, after four months, their cholesterol panel scores are in healthier ranges.  Allow me to get a bit more specific in those areas of change for the better.  By “improved,” I mean: Skin is less dry and certainly more supple with fewer breakouts or acne.  Patients’ moods appear more positive, less depressed, and irritated; wide bipolar mood swings are more stable.  The cholesterol panel numbers are moving in a promising direction.

The two products that I ask my patients to use are made either by Nordic Naturals or Carlson.  I suggest they follow the dosage recommended on the bottle.  Both companies are easy to find nationally, and both test for mercury and pesticides.  However, what is important to me is that neither of these companies sells rancid fish oils.  Most other companies can produce very fishy-smelling and tasting omega-3 fish oils.  Both are earmarks of rancidity.  Rancidity is toxic for human bodies and brains, too.

Nordic Naturals and Carlson produce many fish oil products; I recommend that my clients get a basic one and be consistent about the repeated purchasing and taking of the same product.  Although these two companies cannot claim they produce the cheapest omega 3 on the market, they can make a case for the fact that their products are well worth the prices for uniform freshness, pleasant tastes, and less rancidity.

Occasionally, I do not recommend that a patient take fish oil.  In cases where the person is on a blood thinner, bruises easily, and/or his or her HDL (good cholesterol) score is above 60, I find not taking an omega 3 more appropriate.

Why waste time, money, and your health in the short and long run on fishy smelling, tasting and often burp-producing fish oil pills?  Now, you have a choice.

Once Upon a Time There Was a Whirlwind Named Jane . . .

or Making a Plan to withdraw from Antidepressants

Jane markets software development.  She is a 35-year old “got it together” professional woman.  At least, that’s the way it seems on the outside.  As a networking master, success flows easily for Jane — so easily, that she runs on “automatic” most days.

It’s those early morning mental gymnastic sessions that are driving her nuts!  Months of waking up at 3:00 AM with her mind racing in all directions, from setting appointments with prospective clients that she has been wanting to see for two years to questioning if she wants to have Sam’s babies or not. . .  Jane is beginning to believe that Sam and she have a future together. . .  She used last week’s early wake ups to work through the fact that she and Sam more than like each other and have a chance of creating a long-term relationship. . . 

"Should I be thinking about children when I have a wild obsession with Doritos and dirty martinis?. . .Could that be why I’m gaining weight? . . . I’ll talk to Sam about this tonight.  We’re meeting at the Matador in Ballard for. . . Well . . . it began in my 20’s.   I was a vegetarian . . . About that same time I began taking antidepressants . . . I’ve never been without them . . . Well, for not  more than three weeks since then. . . Could . . . Maybe . . . Hold it!  Hold all those thoughts.  And, hold this thought, too:  I’ve got to get myself together."

For Jane, getting herself together means scheduling a yearly physical with her primary care physician, checking in with her therapist, and taking care of some unfinished matters that she has let ride for too long, like getting off the anti-depressant.         

Several weeks later, Jane’s primary care physician encouraged her to consider seriously dieting because of the history of diabetes in her family.  In the same week, her mental health professional referred Jane to Dynamic Paths to assist her in getting off of antidepressant medications.  While taking the medications, Jane notices she gains weight and she experiences decreasing sex drive.  Over the last few years, she has tried unsuccessfully to stop taking the antidepressants several times.  The time seems right to tackle this issue again, given the positive nature of her relationship with Sam and the momentum building in Jane’s “getting it together campaign”.

Jane read the Dynamic Paths’ website, noted the various services, and spoke to Dr. Allott by phone.  She found out that Dr. Allott and Heather Brummer provide similar assessments and client education in the beginning.  So, Jane decided to set an appointment with Heather, who sees clients after work several evenings a week. 

“I actually liked the idea of two people reading my screening results and thinking about me.  Besides, my initial costs will be a little less when I see Heather Brummer and more within my “getting it together budget.”

Heather and Jane worked together for three appointments and, after some simple dietary changes, Jane was sleeping through the night.  She began to notice she had more energy as well. 

"Is the 'getting-it-together campaign' working?  she pondered. Well. . .  yeah.  I can tell I’m changing and that is encouraging. Yeah, I’m even willing to do a little more in the way of exercising — but, just a little.”

At the end of her third appointment, Heather provided a lab slip from Dr. Allott.  Heather explained that Dr. Allott wanted to be sure that Jane’s body was absorbing nutrients with the new diet changes. “The lab work will allow us to answer this question,”  Heather stated, “Do you have sufficient nutrients for making dopamine and serotonin before starting the weaning-off process from the antidepressant medication?”

Jane’s next appointment was with Dr. Allott to receive results of the blood work.  Now, it was Kristen Allott who spelled out how Jane’s nutrient deficiencies have contributed to her overall fatigue and long-term depression.  In that visit, Dr. Allott asked permission to call Jane’s referring therapist to share the laboratory findings, which confirmed the mental health professional’s intuitions that Jane would need physical as well as emotional support to reach her “getting it together” goals.

Then, Jane returned again to the convenient evening appointments with Heather Brummer, and together they implemented the plan to strengthen Jane’s body.  Jane continued to see her therapist to explore the idea of marrying Sam and having children as well as for support as she learned to managed her broader range of emotions during the withdrawal from her antidepressant medication.

This time — with nutritional support, practical steps, and additional encouragement from Heather Brummer and Dr. Allott — Jane succeeded in reaching her health goals and now she is open for whatever comes next in her life.

My New Favorite Book to Increase Anxiety Tolerance: “Breath” by James Nestor

I am so excited about a new book, Breath: The New Science of a Lost Art, by James Nestor.

Ok, I will admit that I am a little late to the party for the importance of breathing. Not that I was against breathing. I enjoy doing it every 5 to 10 seconds, but it has never been a therapy that I emphasize.

I’ve seen two challenges with breathing practices:

1. In the past, it has always been presented as either a mindfulness practice or an ecstatic practice. In these trainings, no one explained how to breathe in general.

2. When I explained to breathing practitioners that breathing practices increased anxiety in my patients with histories of trauma, no one had an explanation and they recommended that my patients ‘just hang in there'. 

The challenge that people with complex trauma share is that focusing on slowing or controlling their breathing can create more anxiety, and then they feel like they are "failing" at breathing. Instead of a breathing practice,

Instead, I often have my patients name 3-5 colors that they can see around them. This allows the prefrontal cortex and the visual cortex to sit on the amygdala and slow the inner dialog, effectively lowering their anxiety. I thought that naming colors was the same neurological idea of breathing - just a different modality. Plus, I like being able to explain the neurophysiology: vision is at least 30% of our brain.

As a student of psychophysiology, I keep lists of physiology that cause mental health symptoms. When thinking about what can create the physical sensation of fear, independent from present or past emotional causes, I think about:

1. The amygdala being activated by the adrenaline released when the body needs to increase glucose, such as in hypoglycemia.

2. Nutrient deficiencies, such as protein, iron, and B vitamins. 

3. The Vegas Nerve being mechanical pinched at the first and second cervical vertebrae (See Stanley Rosenburg's Book: Accessing the Healing Power of the Vagus Nerve: Self-Help Exercises for Anxiety, Depression, Trauma, and Autism.)

Now, I have a fourth item on my list: Carbon dioxide intolerance caused by survival breathing. 

After reading Breath, I now think very differently about breathing as a tool for healing anxiety. James discusses how people can develop a narrow window of tolerance to carbon dioxide. He shares an example where a woman had no functional amygdala – so no fear responses to spiders, snakes, dangerous people... However, when she inhaled an air mixture with an increased carbon dioxide content, she had a full blow panic attack, and would NOT repeat the experiment.

What I had not appreciated, until reading this book, is that we have chemoreceptors in our brain and in our arteries that are monitoring for carbon dioxide and pH. As carbon dioxide builds up in our bloodstream, it triggers anxiety – sometimes high enough to create a full-blown panic attack.

But, if we don't have enough carbon dioxide in our systems, we can't properly oxygenate our bodies. With breathing patterns that keep carbon dioxide low, our tissues (muscles, digestive system, and brain) suffer from low oxygen states. We can develop fatigue, insomnia, sleep apnea, hypertension, cardiovascular disease, depression, anxiety, inflammation, auto-immune disease and have a weakened immune system. To be physically and mentally healthy, we need to have a range of carbon dioxide that we can tolerate. Studies indicate that people with anxiety have a very narrow range of carbon dioxide levels that they can handle (see links below). 

When we breathe through our mouths, we bring 20% less oxygen into our lungs. Breathing through our noses prepares the oxygen to be absorbed by the lungs into the red blood cells by removing bacteria, viruses, and particulates, increasing the humidity, and slowing the velocity of the molecules so that they can be absorbed into the capillaries carrying the red blood cells.

We need carbon dioxide present in the capillaries of the lungs so that it can exchange places with the oxygen in red blood cells. When we are intolerant of variations in carbon dioxide levels, we tend to breathe through our mouths. This lowers the carbon dioxide levels in our lungs and thereby lowers our oxygen absorption capacity. When we have lower oxygen levels in our bodies, we increase our bodies' stress, which increases our stress-related diseases. 

However, what I was seeing when my patients focused on slowing their breathing was the impact of the increased levels carbon dioxide in their bloodstreams, causing an increased physical sense of anxiety (anxiety not caused by what is externally around them).

Now that I understand the physiological mechanism through which carbon dioxide can increase anxiety, I can more closely screen patients for behaviors that indicate that they may be avoiding the sensation anxiety created by carbon dioxide intolerance. These include: 

• Mouth breathing, while awake or while sleeping

• Poor forward posture, often created by sitting in front of the computer

• Hyperventilation (respiratory rates greater than 10 breaths per minute)

For the people with complex trauma, who often refuse to consider breathing techniques for their anxiety, I now start by explaining that they are not failing at breathing, but rather that they need to develop a slightly larger range of carbon dioxide tolerance. And that when they can tolerate more carbon dioxide, more oxygen will be available to their body, which will help them have more energy and mental clarity. Their brains will begin to wire in that higher levels of carbon dioxide is safe. 

You might be wondering why we, as a species, are so hyper-vigilant to carbon dioxide when it’s so helpful in oxygenating our bodies. The carbon dioxide receptor is one of the oldest receptors found in most life forms. The earliest life forms on the planet were more concerned about getting into a space that was low in oxygen and high in carbon dioxide. This was a safety mechanism to stay alive, which was helpful in the past but not so helpful in our modern life.

Here are the steps that I am using to work with my patients around carbon dioxide intolerance;

1. Ask them to observe if they breathe through their mouths or noses. Times to observe are at work (particularly when working on a keyboard), watching screens, sleeping, and working out.

2. Ask them to focus on lightly closing their mouths when they can. This mindfulness practice will help them be aware of how they breath. When doing this, the patient might notice that they naturally breathe more deeply, using their whole rib cage. Suggesting that they place one hand on their chest and one hand on their belly is another way to help them see what muscles create their inhalation and exhalation. They might notice that they yawn more. I encourage focusing on their breath for at least 3 days, paying attention to what happens to their levels of energy and mental clarity. If they get anxious, they can breathe through their mouths for a time and then go back to breathing through their nose. 

3. Even if they have a stuffy nose, still encourage them to try breathing through their noses. James Nestor, who suffered from allergies, a deviated septum, and often developed pneumonia, found that learning to breath through his nose actually improved these symptoms.

4. Ask if they are willing to lightly tape their mouths shut while sleeping, using a small piece of medical tape or KT tape – about the size of a postage stamp. It’s still easy to open their mouths if they need to, but it’s enough to remind them to keep their mouths shut and to breath through their noses. This decreases snoring and mild sleep apnea, and increases the oxygenation of their tissues.

5. Ask them to try keeping their mouths shut when working out. This will likely be uncomfortable at first, but if they persevere it can increase performance, endurance and recovery.

6. Lastly, ask them to think of breathing as a moment-to-moment practice that can take a lifetime to truly appreciate.  

I hope this summary is helpful to you. Please feel free to email your questions. Your curiosity helps me learn to articulate the science in a usable fashion. Also feel free to share your own stories of breathing by commenting on this post below.

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Related references:

• Here a podcast interview with James Nestor, “How to Fix Your Breathing to Improve Your Health,” at Art of Manliness Podcast with Brett McKay #638 (46 minutes).

• I listened to Breath on Audible. It was a fun book to listen with lots of stories and listening always make the science easier to hear for me. 

• Scientific Papers:

  • “Panic Attacks as a Problem of pH” by By Richard Maddock, May 18, 2010 in Scientific American

  • “The physiological effects of slow breathing in the healthy human”. by MA Russo, Santarelli DM, and O'Rourke D. in Breathe (Sheff). 2017;13(4):298-309.

Key Labs To Rule Out Physical Causes Of Anxiety, Depression and Fatigue

I am so excited to be a part of Dr. Mariza Snyder's podcast, Essentially You. Mariza has spent the last 2 years creating something incredibly valuable to help reinvent your health with safer, more effective natural solutions and powerful lifestyle changes.

As you know, I believe that lab testing is the way to get the inside scoop on what’s really going on in your body and what could be causing your symptoms.

For so long, anxiety, depression, and fatigue have been completely separated from your nutrition, hormones, and physical health. But by understanding what’s going on under the surface, you can take simple steps to heal your mind and body and restore your energy.

Having the right nutrients and balance of hormones in your body can create a mental, physical, and emotional shift that will help you get back to your energized self faster.

Tune in to this episode today to hear me and Mariza talk about exactly what labs to request, how to interpret them, and which nutrients you can start adding to your routines today to experience relief!

Here’s a short video of what you’ll hear on the podcast!

I’m honored to be part of Essentially You!

What can be learned in therapy, with Dr. Jane Tornatore

The Connectors Group
When I work with an individual on improving their energy and mental clarity while also addressing other mental and physical health challenges, I often ask if they have done therapy and, if so, what they learned from it.

Often the response is that they told someone their story of childhood, loss, challenges... This, of course, is important, but what did they learn?

For myself, I has seen several therapists over time. With each therapist, I was mostly unclear about what I was learning at the time; I just wanted to feel better. In retrospect, I can see that I was learning:

• to tell my story and not edit out the uncomfortable moments

• how to have an observational self that is not the internal critic

• how to trust myself and trust others

• how to set boundaries for myself and others

• how to learn from my mistakes

• how to talk small steps forward, rather than try to leap into what I have not experienced before

• how to have hope

Recently, I was talking to my friend and colleague Dr. Jane Tornatore, who is one of the therapists that I refer out to when someone is struggling and is looking for more than “just talking” about what’s going on. I realized that part of why I enjoy referring to Jane is that she’s clear about what skills people need to learn to help their brains better integrate their experiences. Neuroscience supports that it’s this integration that helps people feel more stable and engaged in their lives.

This is a recording of the live webinar with Dr. Jane Tornatore, Dr. Kristen Allott, and Natasha Duarte..

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Meet Dr. Jane Tornatore:

Dr. Jane Tornatore is a therapist, speaker and author based in Seattle, WA. She has been in private practice for 15 years. Her style incorporates compassion, curiosity, deep listening, and heartfelt optimism, along with powerful shots of playfulness. Jane has dedicated her career and her life to helping people love themselves and have self-compassion. She received a Master’s degree at the University of Illinois, and a PhD at the University of Minnesota. Before going into private practice, she spent two decades working in the field of Alzheimer’s, including research and working for the Alzheimer’s Association. She has authored over 20 articles and just published a book—Everything is Perfect, Just Not ME! A Roadmap for Self-Acceptance. Learn more about Jane at: doctortornatore.com

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The Connectors Group consists of a wide range of individuals who are in positions to help other people navigate their lives better: mental health therapists, executive coaches, psychiatric nurse practitioners, supervisors and project managers, lawyers, teachers, and community organizers.

Minimal Metrics for Exercise

In 2018, my blog focused primarily on anxiety. This year I am thinking more about movement and mental health. A good starting place is identifying the minimal metrics for movement and how achieving these metrics can support mental health.

So, I spent some time reviewing the most recent studies for exercise.

What is definitive?

Exercise reduces dementia and reduces all causes of death. For mental health in general, cognitive functioning exercises in studies don’t always show that it is helpful. They have not shown that they decline cognitive functioning. Ok. Exercise dose not always helps to be smarter. But for depression, the research is clear: exercise is an excellent therapy on its own and in conjunction with other therapies. Exercise increases neuroplasticity, improves how the autonomic and endocrine systems respond to stress, improves sleep, improves self-esteem, …the list goes on. So, we can definitely say now that exercise is good for both the brain and body.

How much movement do the studies say is needed?

When people exercise three times a week for 12 to 24 weeks, there is a dramatic reduction of depression, and if the exercise continues, there is a reduction in recurrence. That sounds great! And… those people were selected and paid to be in the studies.

Beyond the studies and in my office

When people can feel that movement improves how they feel, then it becomes a useful tool for treating energy and mental clarity in the moment. I believe that part of treating depression, mental health, pain, and other diseased states, is to provide people with tools that move them towards resilience moment to moment. If a person has a tool that can help them feel better now, today, or later today, we can build experiences that move us away from depression, fatigue, low self-esteem, anxiety, pain, or whatever their points of suffering are. Why does this work? When people can experience change that they are in control of, and learn the value of the process, they have a model of change that can then apply to other things in their life.

But how do you actually get someone who is depressed moving?

At my last PESI training in Richmond, VA, I posed this question to the group of around 90. I like to start with the smallest possible metric, in large part because it is doable. And since I am all about being able to feel what’s going on in the body, I first asked everyone to do an experiment. You, the reader, can do the same experiment now.

The Minimal Movement Experiment

1. Check-in and rate your energy level at this moment, using the scale below.

Now stand up. Choose one of the three possible movements that you will do four times. Here is a video of me squatting, marching and flapping my hands, in case you want to see what I am talking about.

• Chair squats – have a chair behind you and sit down as though you are going to take a seat. Just as the chair touches you, stand back up;

• March in place – with your knees coming up as high as it is comfortable; or

• Overhead hand clap – raise both arms in the air and bring your hands together comfortably over your head. Clap your hands together if that sounds like fun.

Remember one of these, just four times.

3.  Sit back down and re-rate your energy level.

The majority of people in my training reported feeling at least 10% better. So, if you were initially at 6 (out of 10), you might now be at 7… in less than 30 seconds! What could you do with 10% more energy? Do you get up to snack or drink coffee at work when you might just need to move your body a little bit to get some energy and mental clarity?

Where can the experiment be done?

Certainly, YOU can do this experiment anywhere: at the office, in the bathroom, when you get off the couch from watching TV. Additionally, you can try this experiment with clients who present with fatigue or who are kinesics learners. I offer it as a mindfulness exercise for people with childhood history of trauma, as a way got them to learn to listen to their bodies. It is a small enough dose that it is unlikely to make fatigue worse. Maybe nothing is noticed, but they tried something new. I also like to give it to my clients as homework (“Since the exercise was helpful in my office, I would like you to try it when you have been sitting for more than three hours.”)

Throughout the year, I will write more about how to use movement as a way to improve energy and mental clarity.

References:

Medina JL, Jacquart J, Smits JAJ. Optimizing the Exercise Prescription for Depression: The Search for Biomarkers of Response. Curr Opin Psychol. 2015;4:43-47. doi:10.1016/j.copsyc.2015.02.003. Link to study.

Belvederi Murri M, Ekkekakis P, Magagnoli M, et al. Physical Exercise in Major Depression: Reducing the Mortality Gap While Improving Clinical Outcomes. Front psychiatry. 2018;9:762. doi:10.3389/fpsyt.2018.00762. Link to Study.

New Study: Nutrition is a Cost Effective Tool for Major Depression

Since Felice Jacka’s landmark study in 2010, accumulating evidence shows that poor nutrition contributes to depression and anxiety. For years studies have shown the importance of B vitamins, omega 3 fats in the form of EPA and DHA, and individual amino acids for correcting depression. Dr. Felice Jacka pioneered research demonstrating that whole food nutrition counts for adults and adolescents in treating depression and anxiety.

A new study (SMILES) provides evidence that that nutrition is a cost-effective treatment for major depression. The prospective research comes from Australia and New Zealand where they enlisted 67 adults meeting the criteria for a poor-quality diet and major depression. These individuals were randomized in one of two arms of the study: nutrition support (33 people) or social support (34 people). The nutrition arm provided up to seven sessions with a nutritionist, and the social support provided the same amount of time and emotional intensity. The study took into consideration both healthcare costs and time lost at work from major depression. Below is a summary of the significant findings of the study.

Nutritional intervention: 33 people received 7 sessions with a nutritionist for support enacting the Mediterranean diet

Positive Findings

• Higher remission rates of major depression

• Lower missed paid and unpaid work days

• Lower use of health care services

• Overall health care costs on average was $940 lower

• Lost productivity costs were $1589 lower

Downside costs

• Higher cost of session delivery, travel and food costs

Social Support: 34 people received seven sessions of social support. No nutritional changes.

Positive Findings

• Lover cost of session delivery, travel and food costs

Negative findings

• Lower recovery rates and lower remission rates of depression

• More use of allied professionals occupational therapists, such as: physiotherapists, osteopaths dentists, podiatrists, orthodontists

• More lost productivity due to missed paid and unpaid work days.

• Higher health care costs and lost productivity costs

Although this is a small study, the accumulating scientific evidence suggests that nutrition provides support for depression as a therapeutic tool. Additionally, major depression increases the risk of diabetes, cardiovascular disease, and obesity. All of these conditions are costly to the person, negatively impact productivity at work, drive health care costs up, and have studies associated with them that show nutrition can slow or reverse the disease. When we are connected to a person suffering from depression helping them take action to address the depression can be life-changing.

The typical therapeutic tools for major depression are psychotherapy, medications, and maybe mindfulness. If nutrition is going to be referred to, we have to create a path that lowers the shame. Most people believe that they should be able to improve their diet on their own and recognize that they don't--causing shame.

I want to review some options for getting traction when examining a person’s diet, used in the context of a therapeutic ally or psychotherapist.

Possible Experiments

1. First, I am going to refer to our previous blog about Hope Rising by Chan Hellman, Ph.D. When someone is stuck in depression it is possible that they are missing some important tools. Dr. Hellman discusses that for Hope to exist we have to have both Waypower and Willpower to achieve our goals. In other words, we need to have a path with small achievable steps laid out, and we need willpower which is a personal investment in our goal and good nutrition to keep us in our pre-frontal cortex (the "smart brain") and out of our the limbic system (the "lizard brain"). So when I am discussing the causes of depression with someone, I try to identify whether they know what the next couple of steps are toward a goal -- any goal, or if they do not have the will power to move forward. If they don't have the willpower and their diet is low in nutrients, I will start doing 3-day experiments with food or movement/exercise. (See my handout on 3 Days of Protein to increase energy and mental clarity).

2. From a motivational interviewing perspective, giving them a choice on what they are willing to try to address their depression and then set a time to see if the therapy helped. For example, I will go see a nutritionist 7 times over 12 weeks. I will walk every day for 10 minutes for 30 days.. The activities can include medication, nutrition, mindfulness, movement/exercise, or a gratefulness diary, to name a few. Put a timeline on how long you will try that path before trying another path.

3. At the start of a relationship, or when a client reports a particularly bad day, simply ask, “What did you eat yesterday?” The brain needs fuel just like the body and sometimes what and when we eat or don’t eat has an influence on how we feel. One child therapist I know asks the parents when they meet, "What is happening in the home?" She always follows up with questions about what the child has been eating. She barely has to comment on the cereal, pizza and mac and cheese pattern for them to notice the relationship between the food quality and their child's behavior. Our intention of healthy meals easily becomes lost in the busyness of life.

4. If a person is stuck in their depression, ask if they are willing to do an experiment for 3 days to change their nutrition. We have a video and a handout on increasing protein to improve energy and mental clarity. Note that some people may not be able to notice a difference until they go back to their original diet.

5. Find a good referral for nutrition in your area. There are many professionals that can discuss nutrition. Here are some professionals to approach possible referrals: nutritionists, acupuncturists, naturopathic physicians, and health coaches, to name a few. One of the important questions to ask is if the person is comfortable helping someone improve their diet without the goal of losing weight. If the depressed person is overweight, I find that it’s important to focus first on having more energy and mental clarity and feeling better day-to-day before embarking on losing weight. Often the loss of fat can make an individual feel bad because fat contains hormones, heavy metals, and other toxins. The release can overwhelm the liver and cause fatigue and distress. Without the right context, this can be confused with depression even though it is a physiological response to losing fat from their body.

We all know that when we feel better, and have more energy and mental clarity, work and life don’t seem as overwhelming and those small steps towards a goal are more accessible. Better management of anxiety and depression through nutritional interventions is a cost-effective way to improve both quality of life and productivity. What are the first steps that businesses can take support their employees on this path?

What diet types contribute to depression and anxiety?

I am reluctant to write this post. I’m sure I’m going to make a few people mad. In last month’s Connectors Meeting there were questions about how different diet types contribute to mental health concerns. When a person's diet choice restricts food categories, they can find over time that their diet is contributing to increased anxiety and depression. This is because a diet that limits food groups can lead to nutrient deficiencies if health metrics are not carefully monitored through diagnostic labs.

In this post I’ll review some things to watch out for when eating significant amounts of highly processed foods, following vegetarian or vegan diets, and keto/paleo/Atikins types of diets.

Highly Processed Food Diets

Diets high in processed foods have been shown to increase depression and anxiety. These are diets with lots of white foods (bread, rice, potatoes, pasta, muffins, bagels, chips, sweets, fast food). With this diet, when I look at an individual's labs what I typically see are deficiencies in nutrients that help to synthesize dopamine and serotonin. Common deficiencies are protein, B vitamins, magnesium, zinc, omega 3, Vitamin D3, and fiber. Additionally, there is increased inflammation as indicated by elevated C-reactive protein (CRP) levels. Inflammation contributes to depression, fatigue, bipolar, cardiovascular disease, dementia, and diabetes, to name a few concerns. Dr. Felice Jacka provides a whole body of research about the impact of diet on mental health. Here is her seminal paper: Association of Western and traditional diets with depression and anxiety in women.

Vegetarian/Vegan

When I see vegetarians and vegans in my office, they tend to be very anxious individuals and the anxiety often leads to depression. I’m not saying that all vegetarians and vegans struggle with anxiety and depression. Rather, that individuals who are anxious and depressed and vegetarian tend to have higher levels of anxiety and depression due to nutrient deficiencies. Their anxiety is often caused by fluctuations in blood sugar levels because of the low carbohydrate to protein ratio in many of the foods they typically consume.

For example, let’s consider a bean burger. Beans have some protein and some carbohydrates. The bread is all carbohydrates. So this bean burgers contain a lot of carbs and not a lot of protein

Clinically, I have seen anxiety decrease significantly when we assure that they are getting enough protein throughout the day (8 grams per 20 pounds of body weight or at least 65 grams divided throughout the day for anyone over 140 lbs.)

There is a large body of research that suggests vegetarians have better physical health then omnivores. Vegetarians tend to have lower body mass index and cardiovascular disease. However, an Australian study with 9113 participants indicated that vegetarians and vegans have more anxiety and depression then omnivores.

Here are two more studies that may be of interest:

• Vegetarian diet and mental disorders: results from a representative community survey

• Food and Nutrient Intake and Nutritional Status of Finnish Vegans and Non-Vegetarians

For vegetarians, the labs that I carefully look at are total protein, Omega 3, ferritin (iron stores), B vitamins, and Vitamin D3. In my client base, vegetarians and vegans tend to carry less muscle mass and more fat mass.

For vegans, I will also look to see what their primary sources of fats are. The addition of coconut milk and oil can help with fatigue caused by a lack of cholesterol in their diet; consuming enough cholesterol is important because it helps synthesize hormones.

Keto/Paleo/Atkins

I am going to make a “no duh” statement… But it’s one we often forget: Weight does not determine health.

High-fat mass can impact health, but it’s not everything. I’m far more concerned about an individual's ability to be self-compassionate, eat primarily health-sustaining foods, engage in some level of regular movement or exercise, sleep well, and have healthy labs.

I have seen a number of individuals who started on a keto diet (low carbohydrate with high protein and high fat) to lose weight. However, after the initiation phase of just meat and fat, they did not add fruits or veggies back into their diets for years. They explain that primary reason for staying with this phase is because adding back fruits and veggies caused them to gain back the weight they had lost. This is true, because when we do quick weight loss programs it’s hard to not do quick weight gain as well. However, there are some serious health consequences not eating fruits and vegetables.

One of the consequences is that they became very low in B vitamins and Vitamin K. For women following this type of dietary restrictions, they started having heavy menses because their blood was not clotting well. This then also led to iron deficiency, which contributed to their story of depression/fatigue.

Check out these articles:

• Intravenous iron for the treatment of fatigue in non-anemic, premenopausal women with low serum ferritin concentration

• Dietary and supplement treatment of iron deficiency results in improvements in general health and fatigue in Australian women of childbearing age.

In conclusion

Diets that support physical health do not always support mental health. Diets that are low in nutrient dense foods can contribute to mental health concerns through presentation of depression/fatigue and hypoglycemia/anxiety. When someone is considering medications or has tried medicines without the expected positive impact, it’s worth suggesting that they ask their primary care providers for a laboratory workup for fatigue. Going to a naturopathic physician, nutritionist, or acupuncturist to have their diet evaluated for deficiencies that could be contributing to their mental health status is also a good option.

Here are some additional resources:

• Handout: Getting Enough Protein/Optimize Your Brain

• Handout: Getting Enough Protein for Vegetarian and Vegans

• Handout: Fruit and veggie All Stars

• Worksheet: Factors to consider before changing your diet

• Worksheet: Snap Shot of Anxiety

• Blog on labs

• Webpage: Labs & Mental Health: CRP

• Webpage: Labs & Mental Health: Ferritin

Mental Illness or Nutrient Deficiencies?

Fuel for Thoughts

    Dr. Felice Jacka

What is fueling the epidemic of mental health? Twelve years ago when I started my clinical practice in Seattle with the idea that food affected mood, people just did not think food was that powerful. Now there is the beginning of a growing movement. The understanding of impact of food and nutrients on mental health is much more common. For instance, the International Society for Nutritional Psychiatry has been started by Dr. Felice Jacka, who was one of the first researchers to show that a processed food diet increases the risk of depression and anxiety.

What if the 22% of women between 40 and 60 years old are on an antidepressant are not suffering from depression but from a nutrient deficiency such as glucose control fluctuations because they don’t eat protein until dinner? Or an iron deficiency because they had 3 children and are now peri-menopasual and have heavy menses. Iron is needed to circulate oxygen in the body and synthesize dopamine and serotonin.

I have created a list of citations that explore how food affects our mood and decision making. Additionally, there is a review for Felice Jacka’s papers that Ashely Lions helped me create. 

If someone you connect to is challenged by lack of energy and mental clarity you, as a curious and kind person, could ask the following:

• "Have you asked your primary care provider to work you up for fatigue? I understand that if you go in and say you are depressed or anxious, they will give you a pill. But if you say you have fatigue, they will do basic lab work.” 
• “I have heard that nutrition is really important for feeling good, can you talk about what you're eating and maybe see if we can find some areas where you can take small steps to see if you feel better? Or maybe your could see a nutritionist?

Dealing with Fatigue or Depression

In the United States, 33.7 million people live with some type of mental health issue. Studies show that prolonged fatigue is linked with anxiety and depression and all too often we assume that these symptoms emotionally driven without taking the time to rule out potential physical triggers, such as hypoglycemia, anemia or even possible drug interactions.

In part, this is because differentiating fatigue from anxiety and depression is hard to do and those suffering often don’t know what questions to ask.

I always recommend that people begin by describing their symptoms to their primary healthcare providers as fatigue rather than anxiety or depression.  The medical questions around fatigue can be answered with a number of blood tests. Be sure to ask for the following labs:

• CBC rules out overt anemia.
• Comprehensive metabolic panel rules out liver and kidney problems and identifies issues with glucose regulation (prediabetes and diabetes directly affect brain function).
• CRP is a metabolic marker implicated in cardiovascular disease, diabetes, obesity, and depression.
• Ferritin levels below 50 correlate with increased fatigue, especially in women.
• Hemoglobin A-1 C is a marker for diabetes. Studies have shown that diabetes predicts depression and depression predicts diabetes. A1C should be below 5.7 to be considered normal.
• Homocysteine levels (a Vitamin B marker) greater than 12 indicate a 70% increase in risk of depression.
• Lipid panel is important in diagnosing cardiovascular disease. Additionally, when total cholesterol is below 120, suicidal ideation increases.
• TSH rules out hypothyroidism or hyperthyroidism.

While there is a cost for running these labs, the cost of treating fatigue strictly as an emotional symptom is even higher. A recent article in Money magazine states that the treatment costs for mental disorders is more expensive than treatment of diabetes or hypertension– and that the cost falls mostly to the patients. Insurance companies put up road blocks for receiving mental health treatment, finding in-network care can be challenging and, if you do, the cost of prescribed medications is high. Very often, mental healthcare is a budget buster. Particularly if the primary care provider, prescriber, or therapist have not addressed the true problem – Fatigue. Nutritional studies are showing that poor nutrition and dysfunctional physiology cause 50% of the symptoms of fatigue.

I've created a sample letter requesting the above blood work from your primary care physician that you can use to help start this discussion.

In addition to asking your healthcare provider for the lab work, I have seen the following self-care steps help in relieving fatigue:

1. Walk outside everyday – move your body for at least 10 minutes.
2. Be in bed for 8 hours a night – even if you’re not sleeping, the rest is helpful.
3. Eat protein with every meal.

If these steps feel hard, ask yourself what you can do to make it happen. Don’t think of it as a lifestyle change, but consider it an experiment. Start with one of the above steps and commit to doing it for at least 3 days to see if it helps.

If there was one solution for fatigue, everyone would be doing it. Ask your provider to rule out the most common causes of fatigue/depression. It may not be all in your head ─ it may be that your body needs help.

References:

• Money magazine: The High Cost of Coping
• Lifestyle factors in preventing mental health disorders: an interview with Felice Jacka

Preventing CEO Burnout

John, the CEO of a mid-size family company, has been putting in 90-hour workweeks for 11 months.  Between the tight economy, an aggressive new competitor, and several family dramas, his taking a vacation now has been out of the question.  It is hard for John to get to sleep; it is even harder for him to stay asleep, and his brain turns off only after several cocktails before going to bed.  John knows that he can’t continue this pattern, but he doesn’t know how to stop, or frankly, what else to do.

One night recently, he woke up gasping for air.  John and his wife thought that he might be having a heart attack and frantically called 911.  As they waited for the ambulance’s arrival, several heavy thoughts registered in a back corner of John’s mind.  He was simultaneously afraid and relieved:  Afraid . . . This is it!  I’m going to die.  And yes, relieved:  Why, if I were to survive the heart attack, I might actually get a break!

At the ER, the medical team conducted blood tests and monitored his heart.  After several hours, the team informed John that he had experienced a panic attack.  He was given two prescriptions and encouraged to check in with his primary care physician as soon as possible. The first prescription was for four days worth of Clonazepam, a benzodiazepine that immediately quiets the brain, but is very addictive.  Also, the ER doctor prescribed Celexa, an antidepressant that aids in reducing anxiety.

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The experience stunned John.  “I’m not the sort of guy who has panic attacks!”  Then, dozens of other questions came:  What does this mean? . . .  Am I not cut out for this level of leadership? . . .  Am I failing and don’t know it? . . . How can I take care of the company and my family, if I am not a strong leader? . . .

After taking a couple of days off, “due to a family emergency,” John returned to work and to the stress that comes with being a man who has many people depending on him and great responsibilities.  Soon, getting access to another Clonazepam tablet became a daily matter for him - a disturbing and frightening concern because he has seen other family members struggle with addictions to prescription drugs.  He called his family physician whose only suggestion was to take time off.

On Tuesday, May 7, 2013. The Wall Street Journal published Leslie Kwoh’s article “When the CEO Burns Out.” She listed fatigue, resentment, and loneliness as causes for burnout.  She gave examples of well-known companies that have lost valuable leadership, when men and women took vacations and/or left to recover physically and mentally.   As remedies. she suggests time off and medications, as needed.

Wait a minute.  We can do better than that!  CEO and C-suite executives do not burn out.  Their brains and bodies do! These same brains and bodies begin to break down when they are exposed to chronic stress.  A common symptom of CEO breakdown caused by chronic stress is loss of a person’s ability to focus. 

In prudent organizations today, leaders understand that executive brains and their physical well-being are the most important assets of any venture.  Therefore, owners and boards of directors anticipate their organization’s needs; after all, they are used to essential scheduled maintenance on machines.  It’s required for all human assets too!

The idea is a sound one.  Therefore, it doesn’t take long for someone to ask: What should be included in an organization’s prevention plan for executive burnout?  At a minimum plans should include:

 1.    Instilling in your corporate culture the behaviors that increase the body’s ability to cope with stress.  These tenants are eight hours of sleep, 30 minutes of exercise daily, and at least three meals with protein and vegetables per day. 

 2.   Insisting on time away:  Our brains function better when we take time away from complexity and sameness.  Rest, relaxation, and discontinuous time and activities produce fresh perspectives - essential in thinking strategically.

 3.  Scheduling annual physical examinations with primary care physicians for C-suite executives.  Metrics of high blood pressure, high cholesterol, and weight gain are symptoms of a body not handling stress well.

Rather than being surprised and in crisis when an executive must step out or step down, which is extremely costly, why not create a preventive maintenance plan for key executives in your organization?