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Diet and Depression
Diet and Depression
R E V IE WS
Summary
Depression in adolescence is associated with a range of negative outcomes and substantial risk for morbidity and mortality across the lifespan. Dietary improvement
and supplementation may offer an inexpensive and acceptable adjunct to standard
treatment; yet this has, to date, been largely overlooked, owing to lack of evidence
and knowledge. This is important, as improving understanding of the role of diet in
mental health and promotion of appropriate dietary practices could significantly
reduce the personal and social impact of depression in young people. This article
sets out to review the existing research literature on associations between diet and
mental health in adolescence, in particular, the role of diet in the prevention and
management of adolescent depression. A closer examination of associations
between obesity and depression is also included, as these two conditions often cooccur. Research into diet and mental health tends to fall into two main categories:
population-based observational studies and intervention studies; however, there is
very little research evidence specific to adolescents. Potential implications for mental healthcare policy and practice are discussed.
Keywords: adolescence, depression, diet, nutrition, obesity, supplements
Introduction
Depression is a psychiatric disorder, with the core defining feature being a change from pleasant to unpleasant
mood, commonly termed dysphoric. In children and
adolescents, dysphoric mood may present as irritability
rather than sadness or depression. A mood shift is experienced as pervasive, persisting over time and place, and
sufficiently severe to interrupt everyday functioning, for
example ability to do schoolwork or enjoy spending time
with friends (APA 1994). A particular and severe form of
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brought about by, or contributed to, the mental condition through loss of appetite and poor personal care
during a depressive episode, leading to inadequate
intake. The addition of key nutrients that can contribute
to mental health, such as omega-3 fatty acids and folic
acid, may be particularly helpful in long-standing disorders where disruption of a normal diet has become
chronic. Second, if there is an existing condition where
nutrient absorption, transport or storage is affected,
then pharmacological doses of certain dietary supplements may be required to meet the raised nutritional
need for a particular individual in order to improve his
or her mental health. Third, nutrients may influence the
effectiveness of antidepressant medication. This has
been observed in studies using omega-3 fatty acids and
folic acid in the treatment of individuals with treatmentresistant depression (Godfrey et al. 1990; Coppen &
Bailey 2000; Peet & Horrobin 2002; Su et al. 2003).
Nutrients are essential substrates for brain function;
therefore, treatment effectiveness may be partially determined by an individuals nutritional status (Bodnar &
Wisner 2005). Medication may fail to surmount deficiencies in a poorly nourished brain, commonly found
in depression, hence leading to differences in treatment
outcomes among patients receiving similar medication.
Polyunsaturated fatty acids (PUFA) are key structural
components of phospholipid membranes in tissues
throughout the body and are contained in vast quantities in the brain, where they determine neurotransmitter
function. Therefore, an alteration in the fatty acid composition of cell membranes will impact upon the function of neurotransmitters, such as serotonin, which is
known to influence mood (Salem et al. 2001). Folic acid
and vitamin B12 are required for normal central nervous
system functioning. They may affect mood as they are
required for the synthesis and metabolism of serotonin
(Bottiglieri 2005). Moreover, elevated homocysteine
concentrations are a consequence of folate or vitamin
B12 deficiency, and this could contribute to the pathogenesis of depression, as high levels of homocysteine are
toxic to neuronal cells (Clarke et al. 1998; Mattson &
Shea 2003).
The mechanism by which selenium affects mood has
yet to be specified. However, the metabolism of selenium
in the brain is dissimilar to its metabolism in other organs
and is therefore postulated to influence brain function
(Whanger 2001). Interestingly, when selenium levels are
limited, the brain has priority of its supply over other
tissues, such as the muscle or kidneys (Hawkes &
Hornbostel 1996). Moreover, selenium is needed for
both the synthesis and metabolism of thyroid hormones,
and symptoms of depression have been associated with
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sion, and a failure to examine potential moderating variables, such as gender or ethnicity. Indeed, it is important
that future research tries to identify other potential
moderating factors influencing the relationship between
bodyweight and mood, such as pubertal status, selfesteem, environment and genetics.
Structural abnormalities are observed in depressed
subjects as a consequence of decreased neurogenesis and
neurotrophic factor levels, and evidence exists that neurotrophic and neurogenic actions are involved in the
pathophysiology and treatment of depression. Mice
with the brain-derived neurotrophic factor (BDNF) gene
deleted, demonstrate increases in food intake, bodyweight and locomotor activity (Rios et al. 2001;
Coppola & Tessarollo 2004; Mattson 2005). These
mice also go on to develop insulin-resistance syndrome.
However, all of the above are normalised when mice are
placed under dietary restriction. This is believed to be
because dietary restriction increases the expression of
BDNF (Lee et al. 2002; Duan et al. 2003). On the other
hand, a high-fat and refined-sugar diet has been shown
to reduce hippocampal BDNF expression in rats
(Molteni et al. 2002). Hence, there may be direct effects
of obesity on depression mediated through neurotrophic
and neurogenic factors in the brain, which would be
modified by dietary restriction and reduced bodyweight.
During a depressive episode, some sufferers overeat
carbohydrate-rich food, which, as indicated, is hypothesised to have a medicating effect through increases in
brain serotonin (Wurtman & Wurtman 1995). Therefore, the more carbohydrate is consumed, the greater the
release of serotonin from brain neurons, which could
result in mood improvement. Unfortunately, a likely
consequence of this self-medicating practice is weight
gain, which may compound feelings of depression
(Eisenberg et al. 2003). A higher body mass index has
been shown to influence body image relating to feelings
of body dissatisfaction in adolescents (Rolland et al.
1996; Candy & Fee 1998). Body dissatisfaction has
been associated with depressive symptoms (Eisenberg
et al. 2003), suggesting that the relationship between
obesity and depression may be compounded by negative
feelings about body image.
A negative body image in an overweight person may
lead to intentional food restriction (dieting), where
weight loss may be regarded as the solution for improving self-esteem and mood. However, owing to the cyclical nature of the relationship between dieting, selfesteem and mood, the dieting process may lower mood.
This was observed in a study by Cachelin and Regan
(2006), who reported a positive correlation between
dietary restraint, depression and self-esteem.
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References
Adams P, Lawson S, Sanigorski A et al. (1996) Arachidonic acid to
eicosapentaenoic acid ratio in blood correlates positively with clinical symptoms of depression. Lipids 31: S15761.
Angold A & Costello EJ (2001) The epidemiology of depression in
adolescents. In: The Depressed Child and Adolescent, 2nd edn, (IM
Goodyer ed.), pp. 14378. Cambridge University Press: Cambridge,
UK.
Angold A, Costello EJ, Farmer EM et al. (1999) Impaired but undiagnosed. Journal of the American Academy of Child and Adolescent Psychiatry 38: 12937.
APA (American Psychiatric Association) (1994) Diagnostic and
Statistical Manual of Mental Disorders, 4th edn (DSM-IV). APA:
Washington, DC.
Barefoot JC, Heitmann BL, Helms MJ et al. (1998) Symptoms of
depression and changes in body weight from adolescence to mid
life. International Journal of Obesity and Related Metabolic Disorders 22: 68894.
Bellisle F (2004) Effects of diet on behaviour and cognition in children. British Journal of Nutrition 92 (Suppl. 2): S22732.
Benton D, Griffiths S & Haller J (1997) Thiamin supplementation,
mood and cognitive functioning. Psychopharmacology 129:
6671.
Bjelland I, Tell GS, Vollset SE et al. (2003) Folate, vitamin B12,
homocysteine, and the MTHFR 677C->T polymorphism in anxiety
and depression: the Hordaland Homocysteine study. Archives of
General Psychiatry 60: 61826.
Block ER & Edwards D (1987) Effect of plasma membrane fluidity on
serotonin transport by endothelial cells. American Journal of Physiology 253: C6728.
Bodnar LM & Wisner KL (2005) Nutrition and depression: implications for improving mental health among childbearing-aged
women. Biological Psychiatry 58: 67985.
Borges BF, Jorge MR, Morgan CM et al. (2002) Binge eating disorder
in Brazilian women on a weight loss program. Obesity Research 10:
112734.
97
Bottiglieri T (2005) Homocysteine and folate metabolism in depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry 29: 110312.
Brewis A (2003) Biocultural aspects of obesity in young Mexican
schoolchildren. American Journal of Human Biology 15: 44660.
Britz B, Siegfried W, Ziegler A et al. (2000) Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity
an in obese adolescents ascertained via a population based study.
International Journal of Obesity and Related Metabolic Disorders
24: 170714.
Brooks TL, Harris SK, Thrall JS et al. (2002) Association of adolescent risk behaviours with mental health symptoms in high school
students. Journal of Adolescent Health 31: 2406.
Cachelin FM & Regan PC (2006) Prevalence and correlates of chronic
dieting in a multi-ethnic US community sample. Eating and Weight
Disorders 11: 919.
Candy CM & Fee VE (1998) Underlying dimensions and psychometric properties of the eating behaviours and body image test for preadolescent girls. Journal of Clinical Child Psychology 27: 11727.
Carney MW, Chary TK, Laundy M et al. (1990) Red cell folate concentrations in psychiatric patients. Journal of Affective Disorders
19: 20713.
Clarke R, Smith AD, Jobst KA et al. (1998) Folate, vitamin B12, and
serum total homocysteine levels in confirmed Alzheimers disease.
Archives of Neurology 55: 144955.
Contento IR, Randell JS & Basch CE (2002) Review and analysis of
evaluation measures used in nutrition education intervention
research. Journal of Nutrition Education 34: 225.
Coon KA, Goldberg J, Rogers BL et al. (2001) Relationships between
use of television during meals and childrens food consumption patterns. Pediatrics 107: E7.
Coppen A & Bailey J (2000) Enhancement of the antidepressant
action of fluoxetine by folic acid: a randomised, placebo controlled
trial. Journal of Affective Disorders 60: 12130.
Coppola V & Tessarollo L (2004) Control of hyperphagia prevents
obesity in BDNF heterozygous mice. Neuroreport 15: 26658.
Davidson JR, Abraham K, Connor KM et al. (2003) Effectiveness of
chromium in atypical depression: a placebo-controlled trial. Biological Psychiatry 53: 2614.
Duan W, Guo Z, Jiang H et al. (2003) Reversal of behavioural and
metabolic abnormalities, and insulin resistance syndrome, by
dietary restriction in mice deficient in brain-derived neurotrophic
factor. Endocrinology 144: 244653.
Edwards R, Peet M, Shay J et al. (1998) Omega-3 polyunsaturated
fatty acid levels in the diet and in red blood cell membranes of
depressed patients. Journal of Affective Disorders 48: 14955.
Eisenberg ME, Neumark-Sztainer D & Story M (2003) Associations
of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics and Adolescent Medicine 157: 7338.
Erickson SJ, Robinson TN, Haydel KF et al. (2000) Are overweight
children unhappy? Body mass index, depressive symptoms and
overweight concerns in elementary school children. Archives of
Pediatrics and Adolescent Medicine 154: 9315.
Fava M, Borus JS, Alpert JE et al. (1997) Folate, B12 and homocysteine in major depressive disorder. American Journal of Psychiatry
154: 426.
Fleming J, Offord D & Boyle MH (1989) The Ontario Child Health
Study prevalence of childhood and adolescent depression in the
community. British Journal of Psychiatry 155: 64754.
98
D. J. Bamber et al.
Fombonne E, Wostear G, Cooper V et al. (2001) The Maudsley longterm follow-up of child and adolescent depression. 1. Psychiatric
outcomes in adulthood. British Journal of Psychiatry 179: 21017.
Fontelle LF, Mendlowicz M, de Menezes GB et al. (2003) Psychiatric
comorbidity in a Brazilian sample of patients with binge-eating
disorder. Psychiatry Research 119: 18994.
Frangou S, Lewis M & McCrone P (2006) Efficacy of ethyl-eicosapentaenoic acid in bipolar depression: randomised double-blind placebo-controlled study. British Journal of Psychiatry 188: 4650.
French SA, Story M, Neumark-Sztainer D et al. (2001) Fast food restaurant use among adolescents: associations with nutrient intake,
food choices and behavioural and psychosocial variables. International Journal of Obesity 25: 182333.
Fulkerson JA, Sherwood NE, Perry CL et al. (2004) Depressive symptoms and adolescent eating and health behaviours: a multifaceted
view in a population-based sample. Preventive Medicine 38: 86575.
Gesch CB, Hammond SM, Hampson SE et al. (2002) Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young prisoners. British Journal of Psychiatry
181: 228.
Gillman MW, Rifas-Shiman SL, Frazier AL et al. (2000) Family dinner and diet quality among older children and adolescents. Archives
of Family Medicine 9: 23540.
Godfrey PS, Toone BK, Carney MW et al. (1990) Enhancement of recovery from psychiatric illness by methylfolate. Lancet 336: 3925.
Goodman E & Whitaker RC (2002) A prospective study of the role of
depression in the development and persistence of adolescent obesity. Pediatrics 110: 497504.
Green H, McGinnity A, Meltzer H et al. (2005) Mental Health of
Children and Young People in Great Britain, 2004. A Survey Carried out by the Office of National Statistics for the Department of
Health and the Scottish Executive. HMSO: Norwich.
Gregory J, Lowe S, Bates CJ et al. (2000) National Diet and Nutrition
Survey: Young People Aged 418 Years, Vol. 1 Report of the Diet
and Nutrition Survey. The Stationery Office: London.
Hallahan B & Garland MR (2004) Essential fatty acids and their role
in the treatment of impulsivity disorders. Prostaglandins Leukotrienes and Essential Fatty Acids 71: 21116.
Harrington R (2001) Depression, suicide and deliberate self-harm in
adolescence. British Medical Bulletin 57: 4760.
Harrington R (2003) Adolescence. In: Unipolar Depression:
A Lifespan Perspective, (IM Goodyer ed.), pp. 6793. Oxford
University Press: Oxford, UK.
Harrington R, Fudge H, Rutter M et al. (1990) Adult outcomes of
childhood and adolescent depression. I. Psychiatric status. Archives
of General Psychiatry 47: 46573.
Hawkes WC & Hornbostel L (1996) Effects of dietary selenium on
mood in healthy men living in a metabolic research unit. Societies of
Biological Psychiatry 39: 1218.
Henderson L, Irving K, Gregory J et al. (2003) The National Diet and
Nutrition Survey: Adults Aged 1964 Years, Vol. 3 Vitamin and
Mineral Intake and Urinary Analytes. The Stationery Office:
London.
Henley WN & Koehnle TJ (1997) Thyroid hormones and the treatment of depression: an examination of basic hormonal actions in
the mature mammalian brain. Synapse 27: 3644.
Herva A, Laitinen J, Miettunen J et al. (2006) Obesity and depression:
results from the longitudinal Northern Finland 1966 birth cohort
study. International Journal of Obesity 30: 5207.
Hysenbegasi A, Hass SL & Rowland CR (2005) The impact of depression on the academic productivity of University students. Journal of
Mental Health Policy and Economics 8: 14551.
Jorm AF, Korten AE, Rodgers B et al. (1997) Belief systems of the
general public concerning the appropriate treatments for mental
disorders. Society of Psychiatry and Psychiatric Epidemiology 32:
46873.
Kovacs M, Goldston D & Gastonis C (1993) Suicidal behaviors and
childhood-onset depressive disorders a longitudinal investigation.
Journal of the American Academy of Child and Adolescent Psychiatry 32: 820.
Kris-Etherton PM, Taylor DS, Yu-Poth S et al. (2000) Polyunsaturated
fatty acids in the food chain in the United States. American Journal
of Clinical Nutrition 71 (Suppl.): 179S88S.
Lamertz CM, Jacobi C, Yassouridis A et al. (2002) Are obese adolescents and young adults at higher risk for mental disorders? A
community survey. Obesity Research 10: 115260.
Lee J, Seroogy KB & Mattson MP (2002) Dietary restriction enhances
neurotrophin expression and neurogenesis in the hippocampus of
adult mice. Journal of Neurochemistry 80: 53947.
Lombard CB (2000) What is the role of food in preventing depression
and improving mood performance and cognitive function? Medical
Journal of Australia 173 (Suppl.): S1045.
McElroy SL, Kotwal R, Malhotra S et al. (2004) Are mood disorders
and obesity related? A review for the mental health professional.
Journal of Clinical Psychiatry 65: 63451.
McLoughlin IJ & Hodge JS (1990) Zinc in depressive disorder. Acta
Psychiatrica Scandinavica 82: 4513.
Maes M, DHaese PC, Scharpe S et al. (1994) Hypozincemia in
depression. Journal of Affective Disorder 31: 13540.
Maes M, Smith R & Christophe A (1996) Fatty acid composition in
major depression: decreased omega-3 fractions in cholesteryl esters
and increased C20: 4 omega 6/C20: 5 omega 3 ratio in cholesteryl
esters and phospholipids. Journal of Affective Disorders 38: 3546.
Mamun AA, Lawlor DA, OCallaghan MJ et al. (2005) Positive
maternal attitude to the family eating together decreases the risk of
adolescent overweight. Obesity Research 13: 142230.
Mattson MP (2005) Energy intake, meal frequency, and health: a neurobiological perspective. Annual Review of Nutrition 25: 23760.
Mattson MP & Shea TB (2003) Folate and homocysteine metabolism
in neural physical plasticity and neurodegenerative disorders.
Trends in Neurosciences 26: 13746.
Mellerup ET & Plenge P (1988) Imipramine binding in depression and
other psychiatric conditions. Acta Psychiatrica Scandinavica Supplementum 345: 618.
MHF (Mental Health Foundation) (2006) Feeding Minds: The Impact
of Food on Mental Health. Mental Health Foundation: London.
Available at: http://www.mentalhealth.org.uk/
Molteni R, Barnard RJ, Ying Z et al. (2002) A high-fat, refined sugar
diet reduces hippocampal brain-derived neurotrophic factor, neuronal plasticity and learning. Neuroscience 112: 80314.
Morris MS, Fava M, Jacques PF et al. (2003) Depression and folate
status in the US population. Psychotherapy and Psychosomatics 72:
807.
Murphy JM, Pagano ME, Nachmani I et al. (1998) The relationship of
school breakfast to psychosocial and academic functioning: crosssectional and longitudinal observations in an inner-city school
sample. Archives of Pediatrics and Adolescent Medicine 152:
899907.
99