Fish is an important component of a healthy diet. Especially fatty fish types such as herring, mackerel, sardines and salmon are often mentioned in relation to brain health. Many people take fish oil capsules aiming to improve their mood or feel more focused, or even in the hopes of preventing dementia. What makes fish, and especially fatty fish, so special?

Fatty Acids
Fatty fish is a rich source of polyunsaturated fatty acids, or PUFA’s (also called omega-3 fatty acids,ω−3 fatty acids, or n−3 fatty acids). PUFA’s come in different kinds, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and α-linolenic acid (ALA). The latter, ALA, is plant-based. It is found in walnuts, chia seed, flaxseed, and vegetable oils. The other two, EPA and DHA, are found in fatty fish. Fish do not produce PUFA’s themselves. Rather, PUFA’s accumulate in fish as they eat
algae or prey fish. In fact, nowadays, to pertain the health benefits of eating fatty fish despite most
consumption fish having lived in captivity, aquaculture feed is artificially enriched with fish oil [1].

Building Block of the Brain
PUFA’s are, quite literally, building blocks of the brain. Especially DHA is highly abundant in the
human brain, where it supports proper functioning of cell membranes. To obtain enough PUFA’s for
optimal functioning, our brains depend largely on what we eat. Mammals, including humans, are
unable to synthesize ALA. This is why ALA is referred to as an essential fatty acid . When ALA is ingested, however, our body can convert it to EPA and/or DHA. Therefore, strictly speaking, DHA and EPA are not essential fatty acids. However, ALA conversion to DHA or EPA is limited: even very high levels of ALA intake cannot fully compensate for the absence of DHA or EPA in a diet [2].

Deficiencies and supplementation
Most dietary advisory bodies recommend a minimum of 200 milligrams of omega-3 fatty acids per day, which equals about one portion of fatty fish per week (see for instance the Eatwell Guide [3]). Especially in countries where fish is not a standard meal component, it can be a challenge to meet this recommendation. For specific groups such as vegetarians or vegans, meeting the recommended intake is virtually impossible. If your diet is deficient in PUFA’s, taking fish oil capsules can be a solution. In fact, gelatin-free capsules are available for vegans and vegetarians, containing PUFA’s from algae rather than from fish.

Fish Oil Capsules to Treat ADHD Symptoms?
Most children in Western countries do not meet the guidelines regarding fatty fish intake [4]. Among youths with attention-deficit hyperactivity disorder (ADHD), even fewer meet the guidelines, resulting in lower PUFA blood-serum levels in children and adolescents with ADHD as compared to their peers without ADHD [5]. This has led researchers to believe that, possibly, low PUFA blood-serum levels may cause attention problems, hyperactivity, and impulsivity. If true, high intake of fatty fish or fish oil supplementation with capsules might reduce ADHD symptoms. To test this promising hypothesis, many researchers have measured symptoms in children and adolescents before and after several weeks of fish oil treatment. Unfortunately, when researchers reviewed all of these studies up until 2012, they concluded that the majority of studies found no beneficial effect of fish oil on ADHD symptoms [6]. Note, however, that this does not preclude the possibility that fish oil supplementation may have a beneficial effect for some children or adolescents with ADHD. Moreover, even if fish oil supplementation does not improve ADHD symptoms, supplementing PUFA deficiencies may provide other health benefits for this group. For instance, it may lower the risk of cardiovascular disease [7].

REFERENCES:
[1] https://www.iffo.net/

[2] Burns-Whitmore B, Froyen E, Heskey C, Parker T, San Pablo G (2019). Alpha-Linolenic and Linoleic Fatty Acids in the Vegan Diet: Do They Require Dietary Reference Intake/Adequate Intake Special Consideration? Nutrients, 11(10):E2365.

[3] https://www.nhs.uk/live-well/eat-well/the-eatwell-guide/

[4] Sichert-Hellert W, Wicher M, Kersting M. (2009). Age and time trends in fish consumption pattern of children and adolescents, and consequences for the intake of long-chain n-3 polyunsaturated fatty acids. Eur J Clin Nutr, 63(9):1071-5

[5] Burgess JR, Stevens L, Zhang W, Peck L (2000). Long-chain polyunsaturated fatty acids in children with attention-deficit hyperactivity disorder. Am J Clin Nutr, 71(1 Suppl):27S-30S

[6] Gillies D, Sinn JKH, Lad SS, Leach MJ, Ross MJ (2012). Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database of Systematic Reviews, 7:CD007986

[7] Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, Summerbell CD, Worthington HV, Song F, Hooper L (2020). Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews, 3: CD003177

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Although you might be under lockdown, you are still allowed to go to the supermarket to buy food. The following information might help in terms of making healthier choices on what foods to buy.

When we are under high stress, we can often reach for foods that are “comforting” (like cookies, donuts, cake, pastries, and chocolate bars), but these foods may not be the best choice for feeding your brain under stressful and demanding circumstances. Comfort foods are often calorie-rich but nutrient-poor.

Further, under high stress (and it doesn’t actually matter what has caused the high stress, whether it be a natural disaster like an earthquake or fire, or witnessing something really traumatic or being stressed because of financial and health uncertainty), the reactions our body goes through can be quite similar. We release adrenaline. This is part of our natural alarm response system.

Adrenaline is an essential neurotransmitter that is released as part of the fight-flight response. It enables our body to get us to safety, shut down non-essential functions, and make sure the muscles needed for flight or flight get activated. Cortisol, a hormone, is also essential for the alarm system to function optimally.

Unfortunately, over extended periods of time, the alarm system can go into over-drive, and this is one factor that can lead to re-experiencing memories, flashbacks, hypervigilance, being on edge all the time, feeling anxious and panicky when reminded of the traumatic event, struggling with sleeping and having nightmares.

Making neurotransmitters (like dopamine or serotonin) and hormones (like cortisol) requires micronutrients, which are numerous kinds of vitamins and minerals. This is a well-established scientific fact. Micronutrients like zinc, calcium, magnesium, iron, and niacin are all essential for making neurotransmitter chemicals for the brain and the body. If your body is depleted of these nutrients, then either it won’t have sufficient nutrients to make these essential chemicals, or it will redirect all resources to the fight-flight response (as it is so vital for survival) and there won’t be much left for ensuring optimal brain function to do things like concentrate, regulate moods and sleep.

Consequently, as micronutrients get depleted at a high rate during times of stress, we need to replenish them in greater quantity from our food (and perhaps other sources).

Where can we get these micronutrients from?

Answer: Nutrient-dense foods; real food, not ultra-processed foods.

Compare a banana to a cookie; one obtains far more of these micronutrients (like potassium, magnesium, folate) that are required for brain function from a banana. Eating kale chips over potato chips would also provide more nutrients. Reaching for a carrot stick and dipping it in hummus would be better for your brain than gorging down a commercial meat pie (although meat pies can be healthy if they contain lots of vegetables too). Choosing nuts and seeds over pretzels would also give you better brain food.

Overall, to cope well with stress your goal should be to increase intake of plant food and food high in nutrient density while still getting adequate protein, fats and carbs. Fish is a great source of protein and of essential fatty acids, which are also vital for brain function. In eating these types of foods, you would be shifting your diet from a Western type of diet (ultra-processed, high in sugar) to a Mediterranean-style diet (high in fruits and veggies, fish, nuts, healthy fats and low in processed foods).

Therefore, stop counting calories and start focussing on nutrients, especially nutrients that are good for your brain!

Would this be sufficient to sooth the over activated alarm system in a situation of high and chronic stress? Possibly, although some people might need more nutrients than what they can get out of their diet, even if it is a healthy one. There are many reasons for this, some of which reflect reduced nutrient density in modern foods, some of which are due to our own specific genetic make-up, and some have to do with the health of our microbiome (the millions of helpful bacteria that live inside us, especially in our gut).

If you do need to consume more nutrients than what you can source from your diet, or you are struggling with cooking due to your particular circumstances and the stresses you are experiencing, or you are time poor because of family or work demands, what do you take in terms of a supplement? Research from the Mental Health and Nutrition Lab in Christchurch, NZ found that following the Christchurch earthquakes as well as other research on stressed communities shows that B vitamins in particular can be helpful. A recently published meta-analysis confirmed the positive effect of B vitamins on reducing stress. In addition, some may find reduction of intrusive thoughts require additional minerals as well.

Basic tips

  1. Start with whole foods diet approach including good fats, nuts, seeds, fish, modest amount of meat, vegetables, fruit, whole grains
  2. Shifting towards eating “real” as opposed to processed foods naturally eliminates unnecessary food additives such as artificial colors, flavors, sweeteners and preservatives that do not add nutritional value and may contribute to psychiatric symptoms in some people
  3. Limit sugar intake (sugar is everywhere in processed foods, energy/fizzy drinks – look at labels to spot the hidden sugar)
  4. Watch caffeine and alcohol intake doesn’t creep up
  5. Eat a good solid nutrient-dense breakfast: e.g., omelette with vegetables, muesli (oats, nuts, raisins) with milk, yogurt, fresh fruit
  6. Aim for 80:20. That is mostly real food but still enjoy treats! And when you do, savour them!

Being in lockdown for some might mean having a lot of extra time on your hands. Maybe take the opportunity to try new recipes, learn what to do with chick peas or how to cook beans, make bread, yogurt or cheese, But overall focus on what you can control. And when it all gets a bit too much, focus on your breath. It is amazing what a few deep breaths, slowly inhaling, holding and exhaling, can do to calm the mind.

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Having Attention Deficit / Hyperactivity Disorder (ADHD) can be quite a burden to someone’s quality of life. People with ADHD generally have problems with regulating their attention and their impulses, resulting in concentration and memory problems as well as reckless behaviour [1]. Luckily, this condition is receiving more attention these days, and an increasing number of people are receiving adequate treatment in the form of medication and/or behavioural therapy. But what is much less known is that many people with ADHD also suffer from other mental and somatic conditions.

The research consortium Comorbid Conditions of ADHD (“CoCA”) investigates the prevalence and the mechanisms of ADHD comorbidity [2]. This research focusses on the four most prevalent comorbidities: depression, anxiety, substance abuse, and obesity. It is important to learn more about these conditions in the context of ADHD, as this can raise awareness among health care professionals. For instance, it can happen that an adult seeks treatment for depression, while this person also has undiagnosed ADHD. What’s more, the ADHD may even be the underlying cause of the depressive symptoms. In this case, it might be better to treat the ADHD symptoms first.

A first step to raise awareness is to map out how often these comorbidities occur together with ADHD. For this, the researchers from the CoCA project have made use of several very large population datasets that contain information of millions of people. From these datasets they can find patterns of ADHD comorbidity. This way they have shown that indeed depression, anxiety, substance use disorder and severe obesity are much more frequent in individuals with an ADHD diagnosis.

Other patterns that emerge from this data is that depression, anxiety and obesity are more frequent in women compared to men in the general population, and this sex-difference is also present amongst individuals with ADHD. This means that when a woman with ADHD seeks treatment, it is especially important to be aware of these other conditions that may increase symptoms and reduce the quality of life.

To learn more about the prevalence of ADHD comorbidities, you can watch this webinar. Here dr. Catharina Hartman and myself explain and discuss the first findings from the CoCA project.

 

REFERENCES:

[1] https://newbrainnutrition.com/adhd/

[2] www.coca-project.eu

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Vegans abstain from all animal products, for example, meat, fish, milk and dairy products, honey and other substances from animal origin, like milk powder. Nevertheless, countless foods remain that are “vegan” by nature: vegetables, fruits, cereals, legumes, rice, nuts, pasta (if made without eggs, of course), and so on. By contrast, vegetarians eat products made of meat but don’t eat meat and fish itself.

Positive results on (mental) health:

  • A raw vegan diet brought a positive change in quality of life, and a decrease of anxiety and stress (3)
  • A low-fat vegan diet for people with diabetes or BMI >=25 over 22 weeks showed that general health, physical functioning, mental health, and vitality improved in the vegan group (4)
  • In the vegan group, lower stress and anxiety were observed. In men, lower anxiety was related to vegan diet; in females, lower stress was related to vegan diet, and a lower daily intake of sweets (5)
  • Vegans tend to be thinner, have lower serum cholesterol, and lower blood pressure, which is reducing their risk of heart disease (6)
  • Vegetarian diet is associated with many health benefits because of its higher content of fiber, folic acid, vitamins C and E, potassium, magnesium, and many phytochemicals and a fat content that is more unsaturated (6)

But is the only difference the food intake? (7)

Vegans/ Vegetarians…

  • smoke or drink less than average
  • exercise more
  • care more about the ethics and quality of their food
  • are less likely to eat fast food

And there are also negative results:

On the contrary there are studies stating that a strictly vegan/vegetarian diet may be a risk factor for mental health; e.g. higher anxiety and depression levels compared to people who also ate meat and other animal products (8, 9).

But this might be explained by a key bias, because the majority of vegan / vegetarian eaters are female, unmarried, younger, and highly educated. These are all characteristics which are associated with a higher prevalence of mental disorders (10).

So, more research is needed until we can state whether a vegetarian or vegan lifestyle might be beneficial for our mental health or not. Generally speaking, enhancing the fruit, vegetable, and legume content of our everyday food will lead to increased uptake of vitamins, minerals, trace elements, and fibers. These are necessary for a physically healthy lifestyle – and most likely for your mental health status, too.

REFERENCES:

  • Healthy food is key to a healthy mind (2017, October 9) retrieved 3 February 2020 from https://medicalxpress.com/news/2017-10-healthy-food-key-mind.html
  • Skopos (2016): 1,3 Millionen Deutsche leben vegan.
    Online unter: https://www.skopos-group.de/news/13-millionen-deutsche-leben-vegan.html [11.06.2019]
  • Link, L. B., & Jacobson, J. S. (2008). Factors affecting adherence to a raw vegan diet. Complementary therapies in clinical practice14(1), 53–59. doi:10.1016/j.ctcp.2006.12.005
  • Katcher, H. I., Ferdowsian, H. R., Hoover, V. J., Cohen, J. L., & Barnard, N. D. (2010). A worksite vegan nutrition program is well-accepted and improves health-related quality of life and work productivity. Annals of Nutrition and Metabolism56(4), 245-252.
  • Beezhold, B., Radnitz, C., Rinne, A., & DiMatteo, J. (2015). Vegans report less stress and anxiety than omnivores. Nutritional neuroscience18(7), 289-296.
  • Winston J Craig, Health effects of vegan diets, The American Journal of Clinical Nutrition, Volume 89, Issue 5, May 2009, Pages 1627S–1633S, https://doi.org/10.3945/ajcn.2009.26736N
  • Veganism and Vegetarian Effects on Mental Health, retrieved 3 February 2020 from (https://www.serenitymaliburehab.com/veganism-vegetarian-effects-mental-health/
  • Lavallee, K., Zhang, X. C., Michalak, J., Schneider, S., & Margraf, J. (2019). Vegetarian diet and mental health: Cross-sectional and longitudinal analyses in culturally diverse samples. Journal of affective disorders248, 147-154.
  • Hibbeln, J. R., Northstone, K., Evans, J., & Golding, J. (2018). Vegetarian diets and depressive symptoms among men. Journal of affective disorders225, 13-17.
  • Sind Veganer eigentlich Veganerinnen?, retrieved 3 February 2020 from

https://vegawatt.de/vegan-leben/sind-veganer-eigentlich-veganerinnen

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In September 2019 the Ig Nobel Prizes were awarded at the renowned Harvard University. Contrary to the well-known Nobel Prize, the Ig Nobel Prizes are awarded annually to “honor achievements that first make people laugh, and then make them think.” As a psychologist in the New Brain Nutrition team, I am interested in the effects that diet can have both on your physical, but especially on your mental health. So one of the award winners especially caught my attention: Silvano Gallus from the Mario Negri Institute in Milano, Italy, was awarded the satiric prize for his research showing that pizza might protect against illness and death – if the pizza is produced and eaten in Italy. In several case-control studies, he investigated the role of pizza consumption with regard to the likelihood of being diagnosed with various kinds of cancer (1). By comparing the amount of pizza consumption in more than 3000 cancer patients and in close to 5000 patients admitted to hospital for other reasons, he found out that the likelihood of developing cancer was markedly reduced if pizza was consumed regularly. The largest effect was found for oesophageal cancer where the so-called odds-ratio was 0.41. An odds-ratio describes the relative risk in comparison to another group, whose risk is set to 1. This means that if you are a pizza lover, chances to develop this kind of cancer are less than half in comparison to people who never eat pizza.

On the other hand, Gallus also stresses that in the US, an effect in the opposite direction has been reported, so that – in this case, regarding prostate cancer – the risk of developing cancer rose with the amount of pizza consumed. So this might be an effect specifically for Italy.

One possible explanation might be that in Italy, as well as in several surrounding countries, a Mediterranean diet is frequently followed. Gallus and colleagues state in their publication that it might be the tomato sauce, olive oil and fresh toppings that account for this effect, and not the whole pizza. A Mediterranean diet is rich in fresh, colorful vegetables, fish, olive oil, and whole-grain flour products, and it has been shown to prevent many chronic diseases. A standard pizza produced and consumed in the US might not meet the criteria for a balanced, Mediterranean-style diet. We at New Brain Nutrition are also investigating the role of the Mediterranean diet on psychological well-being and mental illness.

If you want to find out more about the Mediterranean diet and its effects on mental health, check out our other blogs, watch our cooking videos with Sebastian Lege or download our tip sheet with helpful tips on how to make your diet more Mediterranean.

REFERENCES:

(1) Gallus, S., Bosetti, C., Negri, E., Talamini, R., Montella, M., Conti, E., Franceschi, S. and la Vecchia, C. (2003) DOES PIZZA PROTECT AGAINST CANCER?, Int. J. Cancer: 107, 283–284

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Traditionally, cholesterol levels are associated with elderly people having to watch their diet and possibly take statins to prevent excessive cholesterol in their blood from causing cardiovascular problems [1]. But too low levels of cholesterol can also cause problems. Being an essential building block of both hormones and cell membranes insufficiency of cholesterol can lead to psychopathologies like aggression towards others and self, impulsivity and suicide [2]. Considering that about 25% of the body’s cholesterol is found in the brain it is not surprising that this lipid is associated with behaviour [3].

Based on data collected in the Estonian Children Personality Behaviour and Health Study (ECPBHS) we were able to study the association between cholesterol levels in the blood and impulsivity as measured by Adaptive and Maladaptive Impulsivity Scale (AMIS) at the ages of 9, 15, 18 and 25 years [4]. We first used a longitudinal analysis to investigate whether impulsivity in adulthood can be predicted from cholesterol levels in childhood. Our results showed that only in boys low cholesterol measured in childhood and early adolescence is a valid predictor of impulsivity in adulthood. In girls, cholesterol did not predict impulsivity in any age-groups. The gender differences may relate to the central serotonergic function, one of the possible mediators of blood serum lipid levels and impulsivity [5]. Serotonin pathways function as a behavioural restraint system that inhibits impulsive behaviour and has been shown to differ between sexes [6].

In addition to the longitudinal effect, we also investigated the link between cholesterol and impulsivity cross-sectionally in both childhood and adulthood. In this analysis, we found no correlations. This means that cholesterol levels in childhood are not associated with levels of impulsivity during childhood and cholesterol levels in adulthood are not associated with impulsivity levels in adulthood. There was no difference between men and women. These findings are inconsistent with the longitudinal findings described above. A possible explanation of these inconsistencies is that low cholesterol levels have an effect on behavioural measures only during a specific period, and not throughout life. In addition, cross-sectional relationships may be inconsistent simply because impulsive behaviour is a developmental outcome of the interaction of past cholesterol levels and accumulating experiences. Cross-sectionally measured cholesterol may not adequately represent the effect cholesterol has on behavioural measurements.

Third, we distinguished between two types of impulsivity: adaptive and maladaptive. Adaptive impulsivity is characterised as rapid information processing when such a strategy is rendered optimal by an individual’s other personality traits [7]. Maladaptive impulsivity can be described as a tendency to act without forethought and adequate processing of information as well as without regard to the negative consequences of these reactions. While adaptive impulsivity can be beneficial, maladaptive impulsivity carries mostly negative consequences. The results of our study indicate that low cholesterol levels in boys are predictors of maladaptive, but not adaptive impulsivity as measured by the AMIS questionnaire. Association of only maladaptive impulsivity with cholesterol levels suggests that the impact of cholesterol is specifically on those neurodevelopmental mechanisms that are responsible for the dysfunctional aspects of impulsivity.

We, therefore, concluded that cholesterol levels in childhood only predict maladaptive impulsivity later in life (at least, in boys), but not impulsivity in childhood. Similarly, cholesterol levels in adulthood don’t correlate with impulsivity in adulthood. This conclusion is in line with neurodevelopmental studies highlighting the role of cholesterol during childhood and early adolescence. During that period the development of the prefrontal cortex, part of the brain highly involved in the control of impulsivity, takes place [8,9]. During childhood and early adolescence, the prefrontal cortex and parietal lobes begin a period of prolonged pruning of neuronal axons resulting in thinning of cortical grey matter. It is hypothesised that pruning in the prefrontal cortex represents the growth of frontal control over impulsive behaviour [10].

In conclusion, low cholesterol levels predict high maladaptive impulsivity in adult men already starting from early childhood and do so continuously throughout adolescence. Since cholesterol levels have a great impact on the development of impulsivity starting from an early age and continuing throughout adolescence it can be helpful to measure cholesterol levels already during childhood, the time when neurodevelopmental processes pave the road to future impulsivity.

REFERENCES:

  1. Mehta A, Mahtta D, Gulati M, Sperling LS, Blumenthal RS, Virani SS. Cardiovascular Disease Prevention in Focus: Highlights from the 2019 American Heart Association Scientific Sessions. Curr. Atheroscler. Rep. 22, 3 (2020).
  2. Tomson-Johanson, K. & Harro, J. Low cholesterol, impulsivity and violence revisited. Curr. Opin. Endocrinol. Diabetes Obes. 25, 103–107 (2018).
  3. Dietschy, J. M. & Turley, S. D. Cholesterol metabolism in the brain. Curr. Opin. Lipidol. 12, 105–112 (2001).
  4. Harro M, Eensoo D, Kiive E, Merenakk L, Alep J, Oreland L and Harro J. Platelet monoamine oxidase in healthy 9- and 15-years old children: the effect of gender, smoking and puberty. Prog. Neuropsychopharmacol. Biol. Psychiatry 25, 1497–1511 (2001).
  5. Steegmans PH, Fekkes D, Hoes AW, Bak AA, van der Does E and Grobbee DE. Low serum cholesterol concentration and serotonin metabolism in men. BMJ 312, 221 (1996).
  6. Miyazaki, K., Miyazaki, K. W. & Doya, K. The role of serotonin in the regulation of patience and impulsivity. Mol. Neurobiol. 45, 213–224 (2012).
  7. Dickman, S. J. Functional and Dysfunctional Impulsivity: Personality and Cognitive Correlates. J. Pers. Soc. Psychol. 58, 95–102 (1990).
  8. Casey, B., Getz, S. & Galvan, A. The adolecent brain. Dev. Rev. 28, 62–77 (2008).
  9. Steinberg, L. Neuroscience Perspective on Adolescent Risk Taking. Dev. Rev. 28, 1–27 (2008).
  10. Romer, D. Adolescent Risk Taking, Impulsivity, and Brain Development: Implications for Prevention. Dev. Psychobiol. 52, 263–276 (2012).
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Interview with Annett Oehlschläger, author of the book “You can eat stability?!“

After listening to a talk given by Miss Oehlschläger at a conference on bipolar disorder in 2019, and learning how she, as an affected person herself, manages her disorder, I decided to conduct this interview with her to stress the importance of a solid knowledge about one’s disorder, but also about body processes and nutrition. This interview had been conducted in German and translated to English.

Miss Oehlschläger, after living with the diagnosis of a bipolar disorder for many years, you wrote a book named “Stabilität kann man essen?!“ (“You can eat stability?!“) What made you write this book?

Simply speaking: There hasn’t been a book yet which investigated what effect nutrition, exercise, biological rhythm, sleep, and light have on mood and energy fluctuations. During my literature research I was surprised at first that there were so many connections, and I grew angry because I had never heard about this during my psychiatric treatment. It was my wish that other affected people learn about these connections. This was the reason to write this book.

Who is the book written for and what could be reasons to read it?

So first and foremost, it is written for those who are affected by a bipolar disorder, that’s why it is called “Steps for Self-Management”. But it could also be worth reading for people who don’t get along with psychotropic drugs and for people with other psychiatric disorders than those of the bipolar spectrum.

What does “bipolar pilot” exactly mean?

When I created my website, I was looking for a catchy term and while doing this I actually found the term “pilot.” Even though it has nothing to do with the disorder at all at first sight, it is very suitable. A pilot is someone who is helping a non-local to find the right way and that is how I understand my offer. Everybody has to take the journey on his or her own, I can only accompany a part of it. I make an offer and show how to live self-determined and as autonomously as possible with the disorder. With me as an example, I show how to become an expert of my own disorder. I am there for upcoming questions and I offer my experience and my advice.

Would you say that the book is also worth reading for people without a bipolar disorder or for relatives of people with a bipolar disorder or for people with another mental or psychiatric disorder?

Yes, I’d say so. I have been told several times that my explanations are focused on bipolar disorder, but that many connections are shown that basically affect everyone. Everybody has to eat and everybody wants to stay healthy. The things I’m describing don´t only have to do with the bipolar disorder, but also with how to keep the body healthy, and how close body and mind are connected.

In your experience, how do nutrition and psyche relate to each other?

It has always bothered me that the psyche and the body were perceived as something independent and separate from each other. All materials that our body needs, except oxygen, come into our body via food and drinks, and then the body builds it‘s substances from it and produces the necessary energy. Conversely, what I do not ingest and what the body cannot produce itself, or what it cannot process, cannot be built into the cells. My conviction is that the way people eat plays an important role in all chronic diseases, including bipolar disorder. For people with mental disorders the following relation is important: Emotions and thoughts don’t just materialize out of nowhere. They are built in the brain using amino acids and are controlled by messenger substances. This is quite a complex procedure, but it just doesn’t work right without the necessary raw material. Everybody might have already experienced the feeling of well-being after having eaten something sweet, like chocolate. Here, the connection is obvious. To rephrase a saying by Feuerbach: You are not only what you eat, you also feel according to what you have eaten.

Why is the realization that psyche and nutrition are so strongly connected not widespread and an integral part of every therapy or medical consultation?

I often asked myself the same question while I was reading the books. I asked two doctors who helped me with the diet change. One of them is an internist and environmental physician from Rostock, Germany, and he told me that medical students do not learn this. The focus is rather on the treatment of symptoms, mainly using medication. And I have experienced nothing different in psychiatry, symptoms are treated with medication. The vast potential of biochemistry and orthomolecular medicine remains unused. I find this quite regrettable. Additionally, there are guidelines that are set up by professional societies, and each doctor has to treat according to these guidelines. And then, there is also the healthcare system which is growing more and more specialized. This brings certain advantages, no doubt. But especially when it comes to the psyche, in my opinion, you need a holistic approach to sustainably help an affected person.

In your experience, what do exercise and sleep have to do with the psyche in addition to diet?

This has something to do with a human beings’ system, which has evolved over thousands of years. We are adapted to our environment and living conditions that have evolved only very slowly over the thousands of years. The so-called modern progress over the last 200 years brought so many fundamental changes in our living conditions we are not adapted to – yet. Sensitive people react with disturbances in their system. Bipolar disorder is one of them. A basic element of our living condition was regular exercise. The human being is made for walking and not for sitting. The saying “sitting is the new smoking” states that a lack of exercise is similarly unhealthy as smoking is. When we walk, we release endorphins. These are happiness hormones and pain killers, which made it possible for mankind to run long distances. If you move, you brighten up. I find this a very easy way to lift your mood, you just have to get up and do it.

Further, chronobiology has found out that it is important for our well-being to stick to biological rhythms. If you act against these rhythms you risk affecting your health, i.e., sleeping disorders. This is a common symptom of bipolar disorder and other mental conditions. The sleep-wake-cycle is an important pacemaker, such as sunlight. It is not irrelevant when you eat or sleep when you work or regenerate. Regularity stabilizes. Mental stability can be achieved by living according to these rhythms. I do live according to these principles.

And if we are going to be more practically now, what would you say, which food should one eat?

Of course, all of the food I need for a good mood. These foods have to provide all the 47 substances that each body necessarily needs in order to stay healthy: 10 amino acids, omega-3 and omega-6 fatty acids, 13 vitamins and 22 minerals and trace elements.

However, we don’t eat single substances but complex food. So by selecting my food, this is what I do: If I am aware that drive and mood are dependent on amino acids, then the logical conclusion is that I eat food that contains these. Proteins are built from amino acids. Enhancing your protein intake doesn’t necessarily mean eating more meat. Fish, eggs, and legumes contain protein as well.

Further, many processes in my body require enzymes, co-enzymes and co-factors: This is where vitamins, minerals and trace elements come into play. They are needed so that the substances eaten can be absorbed by the body, and also by the brain. If I know that, then I am aware that I have to eat food that provides these substances – these are mainly vegetables, nuts, seeds, and fruit.

Going shopping at the supermarket, I often get the impression that these foods only account for a small proportion of the vast offer. More dominant are sugar-sweetened beverages, alcohol, packed and conserved foods, bread, bakery products, and candy. We are constantly exposed to these temptations. If you want to eat according to what your brain needs, you can stick to these easy advices:

Don’t consume sweetened beverages, which also include fruit juice and smoothies, because they contain large amounts of sugars. These simple sugars are mood killers.

Don’t buy processed food. You will recognize processed food mainly because it is packaged and contains a lot of food additives. If there are many different ingredients on the list, chances are quite high that there are additives in it that nobody really needs. Their true serving is to make the product either more tasty – using salt, sugar, flavor enhancers, emulsifiers, and the like, or to enhance shelf life by preservative agents or antioxidants, or to make the product more appealing by adding colorants.

The issue with these unnecessary additives is that they harm the gut – in some people more, in some people less. This can lead to a reduced ability to absorb the substances needed, on the one hand, and on the other hand it can happen that the gut gets leaky and unwanted substances can enter the body. This can also lead to sickness. Both affects drive and mood.

Simply speaking, for a good mood and drive I need foods that are as natural as possible, regionally produced, seasonally, and preferably organic. A large part of my nutrition comes from these foods. If I stick to these principles, I take care of a good basis for mental stability.

And what about fat?

Fat is an essential substance, too. We could not survive without fat. If you consider that 60% of our brain’s dry matter is composed of fat, that each cell in our body is coated by a double lipid layer, then one can hardly comprehend this fat phobia which has been going on for many years.

However, there is fat that is beneficial for mood and drive, and there is fat that is unfavorable for the psyche. For thinking, we need a properly functioning of signal conduction in the brain. Our feelings are influenced by our thoughts and the other way round, both are a product of our brain. Both affect our behavior – all of which are very complex processes of the brain.

The cells build those fats into their cell walls that the person ingests. For the membranes to be fluid enough they need a certain composition of fatty acids. Here, the synergy between vitamin D and the omega-3 fatty acids EPA and DHA play a crucial role. Vitamin D is needed when neurotransmitters are built, and EPA makes sure that the cell membrane is fluid enough so that the neurotransmitter can be spilled into the synaptic cleft. DHA takes care that the receptor at the post synapse can pick up the signal to be transmitted. This is why I take specific care to take up at least 2 grams of fish oil every day.

Would you say that nutrition ultimately plays a greater role than psychotropic drugs in improving the disease?

From my point of view, in an acute crisis, psychotropic drugs are a blessing. I am convinced that I would not be alive anymore today if I hadn’t received medication.

But what’s bugging me is constant medication. I, too, have been told that I have to take psychotropic medication all my life. I have a different point of view today. To stay stable permanently, I only need medication as long until my body is strong enough to stabilize my psyche.

This is a long-lasting, exhausting, and also pricy process. Not everybody manages that. This is why it might be that somebody still needs to take psychotropic medication.

A diet that provides all the substances my body needs adds considerately to strengthen the overall health and also the immune system. That way, one improves one’s overall quality of life, not only the mental stability. In this sense, nutrition plays a bigger role.

Can an improvement of the disorder solely occur through nutrition?

Bipolar disorder is a serious mental disorder with many causes. Stress plays a pivotal role, my reaction towards it just as well, just as my core beliefs. A sole change in diet can’t change anything about that, it takes psychotherapy and psychoeducation. However, I can influence my vulnerability towards stressors through my diet. For example, a certain level of magnesium is important for being able to relax and to stand above things. Magnesium is also called “salt of inner peace”, and for a reason.

Further, the effect of my diet on my mood is influenced by the origin of my food, and what it contains or doesn’t contain anymore. Take selenium for example. This is very important for the thyroid gland and, by the way, enhances your mood. Through the last ice age, it has been washed out of the ground here in Germany. So if I eat local products, they contain less selenium than food from the US, for example.

If I measure my blood composition and see that I lack a certain substance that I can’t properly ingest via my food, I go for food supplements. I don’t manage to get all the nutrients I need through the food I eat.

But an improvement of the mental disorder depends on many more factors. Nutrition is the most important part, in my opinion, because only through nutrition I get the raw material for the production of neurotransmitters. No drug can achieve that.

To clarify which components are important for a good mood and drive, I like to use the metaphor of a jigsaw puzzle, just as in my book. Only when all the pieces are in place, I get a coherent image – that of mental stability. Which pieces I need are quite specific. But it’s worth it to find that out. My puzzle pieces were psychotropic drugs, psychotherapy and psychoeducation at first. Today I don’t need these components anymore. But other factors play a role now: nutrition, exercise, sleep, stress management, self-care, and a meaningful occupation. And also, regular measurements of blood levels to identify imbalances or low levels of substances at an early stage and being able to react promptly. These are my puzzle pieces for stability, so it’s not nutrition alone.

You have already mentioned the keyword “dietary supplements.” Which dietary supplements should one take, or should you take any at all?

Sometimes I get the impression that when it comes to the topic of food supplements, it is often about opinions and factoids rather than scientific facts. Often it is stated that supplements are unnecessary if you eat healthily because then you get everything you need. Or that supplements have a beneficial effect only for the producers. I have believed such statements for a long time before I started having my blood levels measured. My level of vitamin D had been so low I basically didn’t have any of it in my blood. The level of magnesium had been below the reference value, B vitamins had been at the lower level, not to talk about zinc and selenium, and the overall level of protein had been way too low. And at that stage I had been eating healthily, or I had assumed that my nutrition is healthy and contains everything I need. So there had to be something wrong here, or what was the reason for these results?

Today I know that certain essential substances are not available in our food in adequate amounts – or not anymore. Take selenium for example. It is even more dramatically regarding vitamin D. This can be built by the skin, so technically it is not really a vitamin. Experts, such as Prof. Holick from the US, call it a prohormone, because it is associated with more than a thousand of metabolic processes, and more than 2000 of our 23000 genes depend on vitamin D directly or indirectly. Because of the degree of latitude we live in regarding Germany, between October and April the sun is so low we can’t build vitamin D at all. The angle of the sunbeams is below 45 degrees, and so the UVB part of the sunlight doesn’t reach our skin. However, vitamin D reservoirs are depleted after 4 months, so even after I have built up enough vitamin D during the summer it won’t help me get through the winter. Vitamin D is very important for the mood. Once you experience what a difference it makes if you refill such a lack of a substance you stop believing those depreciative statements, even if they come from a doctor.

My recovery started with heightening my vitamin D level. It was at 7ng/ml and today I make sure it stays around 60-70ng/ml. Since I don’t build it appropriately through sun exposure or food I take supplements. So I supplement what I don’t get otherwise if I see that I’m lacking it.

On the other hand, it’s no use just to take anything just because somebody told me it’s good for me. Everybody has his or her individual metabolism. If two persons eat the same food, blood levels can differ. So supplements are very helpful if they are taken specifically and for a purpose.

People with mood fluctuations or mental issues should know their level of vitamin D, especially if they take psychotropic drugs because these drugs deplete the body’s vitamin D reservoirs. B vitamins are vital because they enable the building of serotonin, the happiness hormone, from tryptophane. B vitamins act as co-factors here; this is why I recommend eating a handful of nuts every day because they are full of B vitamins.

It also needs omega-3 fatty acids, magnesium, iron, zinc, but describing this here would go too far. But I am describing this in my book in detail.

As a last question, which message do you definitely want to transmit to the readers with this interview? Everybody should be worth it him- or herself to stabilize oneself by following a healthy diet. For me, measuring my blood levels is part of it, so really going to the lab to have your status determined and when you add supplements to your diet, to see what happens. And I am convinced that if you fill up such deficiencies, then everyone will experience his or her own miracle, just as I have experienced it. Because nobody believed that one can become psychologically stable by just a change in diet. Even “only” an improvement of the quality of life is an achievement in my opinion. I know enough sufferers who take psychotropic drugs, but still take dietary supplements such as omega-3 fatty acids and vitamin D because they improve their life situation. And that is actually what we want, isn’t it?

Miss Oehlschläger, we that you very much for this interview!

About the author: Annett Oehlschläger has been diagnosed with Bipolar Disorder when she was 47 years old. She has been solely occupied with this disorder for eight years and has been to psychiatric hospitals 24 times during these years. Through psychotropic medication and many hours of psychotherapy, the bipolar phases got shorter and the dose of medication could be reduced – however, Miss Oehlschläger still didn’t really become mentally stable. She set out to search for alternatives. Through a diet and lifestyle change and by tackling her vitamin and mineral deficiencies she has been managing to become stable for six years now. This made her write a book called „Stabilität kann man essen?!“ (“You can eat stability?!” – available in German) which has been sold more than 3000 times so far.

About the interviewer: Anne Siegl, PhD is a psychologist and neuroscientist at Klinik für Psychiatrie, Psychosomatik und Psychotherapie Universitätsklinikum, Frankfurt am Main, Germany. She is researching effects of nutrition on psychological well-being.

This interview has been conducted and translated together with Laura Müller, B.Sc. Laura Friederike Müller, B.Sc., is a Student of Psychology at the Fresenius University of applied Sciences in Frankfurt am Main. At the time of the interview she has been doing an internship in the Eat2beNice project group at the Dept. of Psychiatry, Psychosomatic Medicine and Psychotherapy, Frankfurt, studying the effects of nutrition and lifestyle on mental health.

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Master students, PhD candidates, post-doctoral scientists and other early career researchers are lucky this summer: from 13 – 17 July they can join the first Radboud Summer School on Brain, Bacteria and Behaviour. During this intense week students will learn from various international experts in the field about the gut microbiome – brain axis, get hands-on practice with handling and analysing data and prepare themselves for setting up their own research projects in this exciting new field. The summer school takes place at the Radboud University in Nijmegen, The Netherlands.

The course program includes a wide variety of topics and activities, ranging from state-of-the-art updates on routes of gut-brain communication to hands-on sessions using bioinformatic pipelines for data analysis. For those that still have energy left, the Radboud Summer School organises social events in the evenings, together with students from other summer courses.

Several scientists of the Eat2beNICE consortium are involved in the course, including project coordinator dr. Alejandro Arias Vasquez (who is leading the course), microbiologist dr. Clara Belzer and psychologists dr. Carolina de Weerth and dr. Mirjam Bloemendaal. In addition, experts from other countries will travel to Nijmegen to teach, including dr. Christine Fulling (University College Cork, Ireland), dr. Rochellys Diaz Heijtz (Karolinska Institutet, Sweden) and dr. Leo Lahti (University of Turku, Finland).

More information about the course, fees and registration can be found here: https://www.ru.nl/radboudsummerschool/courses/2020/brain-bacteria-behaviour/

We’re looking forward to an interesting summer!

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Insulin and diabetes
Insulin is a peptide hormone produced by beta cells of the pancreas. It regulates the metabolism by promoting the absorption of glucose from the blood into liver, fat and skeletal muscle cells. When the blood glucose level is high, the beta cells secrete insulin into the blood, and when glucose levels are low, the secretion of insulin is inhibited. If the pancreas produces little or no insulin, it results in type 1 diabetes, while insulin resistance – a condition in which cells fail to respond normally to the insulin – is characteristic for type 2 diabetes.

Insulin signaling in the brain
The brain was traditionally considered to be an insulin‐insensitive organ. While insulin and insulin receptors in the brain were discovered in 19781,2, this discovery was not appreciated until recently, when the role of insulin signaling was shown in disorders of the central nervous system. There are two types of insulin receptor, differing in functionality and distribution: 1) peripheral tissues express predominantly IR‑B, which targets metabolic effects of insulin, and 2) neurons express exclusively the IR‐A. The insulin receptor belongs to the family of tyrosine kinase receptors and is structurally similar to the receptors of neurotrophins, which play an important role in survival, development and the functioning of neurons. Impaired insulin signaling in the brain, which is commonly termed as ‘central insulin resistance’ is now viewed as a pathogenetic mechanism of neurodevelopmental, neurodegenerative and neuropsychiatric disorders

Insulin and excitotoxicity
A recent study showed that insulin can protect against glutamate excitotoxicity4. Excitotoxicity is a pathological process, by which excessive activation of glutamate receptors allows high levels of calcium ions to enter the cell and activate enzymes that damage the cell. This process is implicated in neurodegenerative disorders such as Alzheimer’s disease, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, and Huntington’s disease, affective disorders, traumatic brain injury, stroke.

In this study, effects of short-term insulin exposure on several parameters of excitotoxicity were investigated in cultured rat neurons. Insulin prevented the onset of so-called delayed calcium deregulation, the postulated point-of-no-return in the mechanisms of excitotoxicity. Additionally, insulin improved depletion of the brain-derived neurotrophic factor, which is a critical neuroprotector in excitotoxicity. Also, insulin improved the viability of cells exposed to glutamate. Thus, this study showed that short-term insulin exposure is protective against excitotoxicity, one of the key mechanisms of neurodegeneration, which opens new therapeutic possibilities.

Insulin and Therapeutic Possibilities
Thus, insulin supplementation or enhancement of insulin receptor functioning can be considered as a potential therapy for neurodegenerative and neuropsychiatric disorders. Extensive experimental work is ongoing in order to further uncover the underlying mechanisms of this new function of insulin in the brain and develop effective therapies of neurodegeneration.

REFERENCES:
[1] J. Havrankova, D. Schmechel, J. Roth, M. Brownstein, Identification of insulin in rat brain, Proc. Natl. Acad. Sci. 75 (1978) 5737–5741. doi:10.1073/pnas.75.11.5737.
[2] J. Havrankova, J. Roth, M. Brownstein, Insulin receptors are widely distributed in the central nervous system of the rat, Nature. 272 (1978) 827–829. doi:10.1038/272827a0.
[3] I. Pomytkin, J.P. Costa-Nunes, V. Kasatkin, E. Veniaminova, A. Demchenko, A. Lyundup, K.-P. Lesch, E.D. Ponomarev, T. Strekalova, Insulin receptor in the brain: Mechanisms of activation and the role in the CNS pathology and treatment, CNS Neurosci. Ther. (2018). doi:10.1111/cns.12866.
[4] I. Krasil’nikova, A. Surin, E. Sorokina, A. Fisenko, D. Boyarkin, M. Balyasin, A. Demchenko, I. Pomytkin, V. Pinelis, Insulin protects cortical neurons against glutamate excitotoxicity, Front. Neurosci. 13 (2019). doi:10.3389/fnins.2019.01027.

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The occurrence of placebo effects has been known for a very long time. A first “trick trial” concerning it took place in the late 1500s when instead of holy water, ordinary water was placed in a religious flask and given to a girl who was said to be possessed by the devil – which caused her to contort in pain. Likewise, when priests read a Latin text to the women, misinforming her that it was the Holy Scripture (while in actuality, it was Virgil’s Aeneid) she nonetheless squirmed in agony1.

The placebo effect can be viewed as controversial: on one hand, when doing placebo-controlled pharmacological trials, a strong placebo effect is dreaded as it might lead to a smaller effect size of the active agent and consecutively to failed trials and limits in drug development. In recent years, several psychopharmacological trials have failed to establish new therapy options due to “placebo response rates ruining drug development” ².

There have been multiple interesting outcomes from trials focusing especially on the placebo effect.

When informing a patient that he would be receiving analgesics, the intravenous application of isotonic saline had the same response as a hidden application of 6-8mg morphine³. A trial focusing on migraine patients and treating them with either placebo or rizatriptan found that the efficacies of the active agent labeled as placebo and placebo labeled as rizatriptan were similar. Furthermore, even open-label placebo was superior to no treatment. Authors concluded that increasing “positive” information incrementally boosted the efficacy of both placebo and medication during migraine attacks4. Furthermore, depending on the efficiency of a medication, 20-85% of its “treatment impact” have been found the be caused by placebo effect5.

When talking about placebo, one shouldn’t forget its “evil brother” nocebo, as – like Hansen et al. (2017) expressed in their journal article – you cannot have a placebo without a nocebo effect.

After a lumbar puncture, half of the patients who were told they might experience a headache afterward did have one, whereas of the control group (patients not warned about this side effect), all but one of thirteen remained headache-free6. A meta-analysis of patient expectancy and post-chemotherapy nausea reported a robust positive association between both, suggesting that patients with stronger expectancies experience more chemotherapy-induced nausea7.

In conclusion, the way clinicians introduce a new treatment and explain desired effects and possible side effects shapes the therapeutic outcome more than we believe. Even though physicians, of course, cannot hide possible side effects when informing about treatment options, it is very important to stress positive effects and avoid using words painting negative pictures. Instead of telling a patient “this medication can lead to bleedings”, one might rephrase and say “due to this, blood clotting might be impaired”.

Don’t forget though: as mentioned above, even when knowing they were receiving placebo, pain reduced in patients suffering from migraines compared to pain increasing in the no-treatment group. Therefore, believing that a drug or diet or any other kind of treatment can and will work is one of the most important steps you can take towards it actually helping you.

REFERENCES:
1   Kaptchuk, T.J., C.E. Kerr, and A. Zanger, Placebo controls, exorcisms, and the devil. Lancet, 2009. 374(9697): p. 1234-5.
2  Stahl, S.M. and G.D. Greenberg, Placebo response rate is ruining drug development in psychiatry: why is this happening and what can we do about it? Acta Psychiatr Scand, 2019. 139(2): p. 105-107.
3  Levine, J.D., et al., Analgesic responses to morphine and placebo in individuals with postoperative pain. Pain, 1981. 10(3): p. 379-89.
4  Kam-Hansen, S., et al., Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med, 2014. 6(218): p. 218ra5.
5   Hansen, E., N. Zech, and K. Meissner, [Placebo and nocebo : How can they be used or avoided?]. Internist (Berl), 2017. 58(10): p. 1102-1110.
6   Daniels, A.M. and R. Sallie, Headache, lumbar puncture, and expectation. Lancet, 1981. 1(8227): p. 1003.
7   Colagiuri, B. and R. Zachariae, Patient expectancy and post-chemotherapy nausea: a meta-analysis. Ann Behav Med, 2010. 40(1): p. 3-14.

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This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 728018

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