how to better your mood with healthy food! · we eat 3kg of food and beverages each day and 35% of...

latrobe.edu.au CRICOS Provider 00115M

How to better your mood with healthy food!

Professor Catherine ItsiopoulosElena GeorgeHannah MayrJosephine PizzingaScott TeasdaleDr Wolf Marx

DAA 34th National Conference 20 May 2017 Hobart

2La Trobe University

Overview of Workshop

10.45 – 10.50: Introduction – Catherine Itsiopoulos

10.50- 11.10: Overview of Mediterranean Diet and the Brain (CI)

11.10 – 11.35: Mental Illness, Chronic Disease and Dietary Interventions (Elena George and Hannah Mayr)

11.35-11.45: Morning Tea Break

11.45-12.15: Dietary Interventions for people with Depression and Anxiety (Jo Pizzinga)

12.15- 12.45: Dietary Interventions for people with SMI (Scott Teasdale)


Workshop Objectives

1. Understanding the links between poor physical health and mental health

2. Understanding the role of diet in mental health

3. Strategies for successful dietary behaviour change

460-377 BC

5La Trobe Universityhttp://www.bbc.com/news/magazine-20898379

"I don't eat processed food, I don't smoke and I don't get stressed," says 102 year old George Kassiotis.

"It's the wine," he says, over a mid-morning glass at his kitchen table. "It's pure, nothing added.


Characteristics of “Blue Zones” Populations

Populations around the world living beyond 100 yrs:

Okinawa (Japan)

Sardinia (Italy)

Nicoya (Costa Rica)

Lima Loma (California)

Ikaria (Greece)

Key lifestyle features:

family coherence

no smoking

active social life

very low levels of stress

physical active

a plant-based diet.

www.bluezones.com


Key lifestyle features of Ikarians (Itsiopoulos et al, 2016):

Very low levels of stress, happiness, and positivity

no smoking (in women)

active social life and being productive

family coherence, eating together, lots of festivals

physically active, walking everywhere, keeping a home garden

a high plant-food diet focussed on fresh local foods

free range produce (goats roam free)

www.bluezones.com

Xenia Regina


EVOLUTION???

http://lifedestiny.net/wp-content/uploads/2010/01/EvolutionOfMan.jpg

Somewhere, something has gone terribly wrong!


Food is addictive and today it is cheap and abundant


http://img.theepochtimes.com/n3/eet-content/uploads/2015/02/06/shutterstock_173429666-676x450.jpg

This is not the food variety we need! -> Read Labels- many low fat foods can have added sugars!


Undesirable Food Trends in Australia 2015: What are Australian Eating? (NHS, 2011-2012)

Recent Australian Health Survey of 12,000 people shows that we are eating 30% less fruits and vegetables than 15 years ago.

25% of Adults eat NO vegetables on an average day and only 7% eating recommended 5 serves per day!

Australians are eating an average of 6g of nuts and seeds per day –significantly lower than the recommended 30g/day.

We eat 3kg of food and beverages each day and 35% of energy comes from high fat, high sugar foods such as cakes, biscuits, alcohol, soft drink and chips.


Just over one-third (35%) of total energy consumed was from

'discretionary foods', that is foods considered to be of little nutritional

value and which tend to be high in saturated fats, sugars, salt and/or alcohol. The proportion of energy from discretionary foods was highest among the 14-18 year olds (41%).

Biggest contributors were: cakes, desserts, confectionary, muesli like bars, biscuits, soft drinks, alcohol and flavoured mineral waters

Discretionary food

Australian Institute of Health and Welfare, 2012


Undesirable Physical Activity Trends (AHS, Physical Activity 2011-12)

On average, children and young people aged 5–17 years spent one and a half hours (91 minutes) per day on physical activity and over two hours a day (136 minutes) in screen-based activity with physical activity decreasing and screen-based activity increasing as age increased.

Against the National Physical Activity Guidelines for adults "to do at least 30 minutes of moderate intensity physical activity on most days", only 43% of adults actually met the "sufficiently active" threshold.


The Lancet 2004

Case-control study of acute myocardial infarction in 52 countries,

including 15,152 cases and 14,820 controls from every inhabited

continent;

Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity,

psychosocial factors, consumption of fruits, vegetables, and alcohol,

and regular physical activity account for 90% (M) and 94% (F) of the

Population Attributable Risk of myocardial infarction worldwide in both

sexes and at all ages in all regions.

15La Trobe UniversitySapkota 2013, http://sph.umd.edu/news-item/air-pollution-among-top-global-health-risks

14 out of the leading 20 risk factors are related to diet!


Large Meta-Analyses consistently show that the Mediterranean diet could be a cure-all!

Sofi et al, Adherence to Mediterranean diet and health status: meta-analysis. BMJ 2008:337:1344, Updated Sofi et al, AJCN 2010, Updated Sofi F et al (Public Health Nutrition, 2014)

A review of 18 international studies between 1966-2010 involving 2 Million people, demonstrated that closer adherence to a Mediterranean diet was associated with:

10% reductionoverall mortality

10% reduction in CVD deaths

6% reduction in Cancer deaths

13% reductionIn Alzheimer’s and Parkinsons

Slide courtesy of Prof Catherine Itsiopoulos


Health Benefits of a Mediterranean Diet

Brain- Reduced risk of dementia and Alzheimer’s (Sofi et al, 2014)- Retention of brain volume with ageing -> better cognition?- Reversal of depression and anxiety (Jacka, Opie et al, 2017)

Heart- 30% relative risk reduction in developing heart disease (PREDIMED)- 70% reduced risk of having a 2nd heart attack (Lyon Heart Study)- Polyphenols from EVOO, F&V, nuts, wine reduced inflammation, protect

myocytes from damage, reduce hypertension, improve lipids.

Diabetes & Metabolic Syndrome- 55% reduction in risk of developing diabetes (PREDIMED)- Reduced risk of diabetes complications (Greek Migrant Paradox Study)- Improved glycaemic control (Ajala et al, 2013; Itsiopoulos et al, 2011)- Sustained weight loss over 4 yrs compared to other diets (Shai et al, 2008)- Reversal of fatty liver (Ryan, Itsiopoulos et al, 2013)


Healthy Brain

Healthy Mediterranean-style diet

Olive oil

Fresh fruit/veg

Fish

Legumes, nuts, seeds, cereals

Moderate red wine intake

↓ processed food, red meat, dairy products, calories

▼ MUFA (oleic acid)

Polyphenols

‘Vitamin’ D

Minerals (e.g. iron, iodine, zinc)

Omega-3 PUFA

↑ neuronal survival↑ energy metabolism↑ neurotrophins↓ oxidative damage/

cell death↓ neuroinflammation↑ neurotransmission↑ membrane fluidity↑ cell membrane

integrity↑ glucose transport↑ nutrient synthesis/

metabolism↑ gene expression↑ methylation↓ blood pressure

Vitamins A, B, C, E

Amino acids

Parletta, Milte, Meyer (2013). Nutritional modulation of cognitive function and mental health. J Nutr Biochem

Overview of links between Mediterranean-style diet and healthy brain function via plant compounds/nutrients

20La Trobe UniversityNg et al, 2008


Omega-3 fatty acids in the brain

Crawford & Sinclair 1971; Salem et al 2001; Horrobin 1999; Chalon et al 2001; Youdim et al 2000; Lauritzen et al 2001, Haag 2003; Yehuda et al 2005; Young et al 2005, Parletta et al. 2013

0

5

10

15

20

LA LNA AA 22:4n6 22:5n3 DHA

Brain PUFA fingerprint (% total fatty acids)

Sinclair, unpublished

23La Trobe UniversitySinn et al, 2010, Nutrients, 2:128-170: http://www.mdpi.com/2072-6643/2/2/128/


The Mediterranean Diet is High in Omega-3 fats from a range of sources.

Offal – kokoretsi!

Wild edible leafy greens

Walnuts

Greek village eggs“free range”

fotobank.ru/image/FC01-8880.html

Free range goat- milk and cheese

Snails (Crete)

www.dreamthymefarm.com/goat_meat.html

Pumpkin seeds‘pasatempo’

http://fotobank.ru/image/FC01-8880.html

http://www.dreamthymefarm.com/goat_meat.html


Comparison of eggs from Greek village and US supermarket

Fatty acid Greek Supermarket

Saturated 101 81

MUFA 143 115

n-6 PUFA 23 34

n-3 PUFA 18 1.7

% saturated 40 44

n-6/n-3 1.3 19.4Simopoulos and Sidossis (2000), World Rev Nutr Diet, 87:24-42 (slide courtesy of Prof Kerin O’Dea)


Microbiota and the gut-brain axis

• 100 trillion bacteria live in our gut – more

than cells in our body

• High vegetable, fibre-based diets produce

different gut environment than Western

high fat/carb diet

• Animal studies: link between gut

microbiota and anxiety-like behaviours

• Healthy women: fermented milk product

altered brain centres involved in

processing of emotions

• Altered microbiome and gut permeability

↑ inflammatory pathophysiology of

depression

David et al. 2014, Luna & Foster 2015; Tillisch et al. 2013; Maes et al. 2008; Dash et al. 2014


Historical Overview: Traditional Mediterranean diet studies

7 countries study

(1950s)

Lyon Heart study

(1990s)

Greek Paradox

Intervention (late 1990s)

PREDIMED (2013)

AUSMED Heart Trial

(2014-)

SMILE, MEDINA,

MEDIBRAIN,

AUSMED ASTHMA

Slide courtesy of Prof Catherine Itsiopoulos

MedLeyMediterranean diet for cognitive function and cardiovascular health in the elderly

PREDIMEDPlus

(2013-)

MedDietHigh risk

adults(2016-)

(2013-16)

http://www.google.com.au/url?sa=i&source=images&cd=&docid=WyUe03AHS0B_sM&tbnid=JnwVcyNvmE2JLM:&ved=0CAgQjRwwAA&url=http://www.infoplease.com/atlas/country/spain.html&ei=YsstUvPMNMufiAf6p4GYDA&psig=AFQjCNG1phfSuCITs-GVn7bsIe0wYFp9rA&ust=1378819298936463


La Trobe University Mediterranean Diet Trials in Chronic Disease Management

Mediterranean Diet

AUSMED –secondary

prevention of Heart Disease

MEDINA –reversal of Fatty Liver

AUSMED ASTHMA

SMILE –reversal of Depression

MEDIBRAIN-reversal of cognitive decline

Multi-Centre Trials in Collaboration with Health Services and Industry


Putting the Mediterranean Diet into Practice!

Mental Illness, Chronic Disease and Dietary Interventions


Mental illness, chronic disease and dietary interventionsElena George APD, PhD Candidate, LecturerHannah Mayr APD, PhD Candidate, Lecturer

Department of Rehabilitation Nutrition and SportDiscipline of Dietetics and Human Nutrition20th May 2017


Contents

1. Mental health in chronic disease patients

Is it common? Does it matter?

2. Key principles of a Mediterranean diet and practical components for implementing

Quiz

Overall points

3. Application: a Case study

Bringing it all together


Australian Mediterranean Diet Clinical Trials

Mediterranean Diet

MEDINAFatty Liver

AUSMEDSecondary prevention of

heart disease

SMILESDepression

MEDIBRAINCognitive Decline


How are chronic diseases and mental illness linked?

Psychological

• Chronic diseases can be a life threat or an unpredictable and may be considered stressful

• Disability and impairment have generic stressful consequences (disability, pain, changes in appearance), producing stress.

Physiological

• Depression is associated with a chronic, low-grade inflammatory response

• It is similarly accompanied by increased oxidative and nitrosative stress (O&NS), which contribute to neuro-progression in the disorder.


Coronary Heart Disease and Depression

• Depression is 3 times more common in patients after AMI than general population (Thomas et al., 2006)

• 15-20% patients with AMI meet diagnostic criteria for Major Depression (Lichtman et al., 2008)

• Similar rates in those hospitalised for unstable angina and procedures such as angioplasty, CABG

• Even more present with depressive symptoms at ~65% (Thomas et al., 2001)

• Major depression and elevated depressive symptoms are associated with worse prognosis in patients with CHD

• Dose response relationship with depressive symptoms and cardiac severity and events (Lichtman et al., 2008)


Non Alcoholic Fatty Liver Disease (NAFLD) & Type 2 Diabetes

• In NAFLD depression and anxiety rates as high as 67 and 70% respectively (Youssef et al 2013).

• Depression and/ or anxiety was higher in patients with NASH vs control subjects matched for age, gender, BMI, and waist-hip ratio (63.8% vs. 33.8%) (Elwing et al 2006).

• Over 30% of cirrhotic patients had depressive features, and they experience worse clinical outcomes than non depressed cirrhotic patients (Mullish et al 2014).

• In patients with NAFLD, depression was associated with more severe hepatocyte ballooning (Youssef et al 2013).

• Although there is a strong link with NAFLD with insulin resistance and diabetes mellitus, both associated with depressive and anxiety symptoms (Lustman et al. 2000, Anderson et al.

2002, Winokur et al. 1988 and Koslow et al. 1982).

• The odds of depression people with diabetes were twice that of the nondiabetic comparison group (did not differ by sex, type of diabetes) (Anderson et al. 2001).


Mediterranean Diet


1. What is the main culinary fat in the Mediterranean Diet?

a) Olive oil

b) Extra virgin olive oil

c) High omega 3 fish

d) Nuts


2. Mediterranean diet should constitute what percentage of energy as total fat?

a) Less than 30%

b) 35-45%

c) 40-50%

d) 45-55%


EVOO- more than just MUFAs

Olive Fruit:

• 90–99% - A glycerol fraction or saponifiable fraction contains MUFA’s (Oleic acid)

• 0.4–5% -Non-glycerol or unsaponifiable fraction contains phenolic compounds (Tripoli et al Nutr Res Rev 20015)

• Other high MUFA oils (sunflower and flaxseed) have been ineffective in improving chronic disease risk factors (Harper et al J Nutr 2006) (Aguilera et al Clin Nutr 2004).

Why Extra Virgin Olive Oil?

• Produced from the first and second pressings of the olive fruit, cold-pressing method (no chemicals and only a small amount of heat are applied)

• So? It retains more natural phenols!

At least 36 structurally distinct phenolic compounds


Biological activities of olive oil phenolic compounds

Image from Cicerale et al. Int J Mol Sci 2010


3. Traditionally the Cretans predominantly consumed which varieties of dairy?

a) Full cream milk

b) Goats milk

c) Sheep's milk cheese

d) Yogurt and fetta cheese


Fermented dairy and other foods

• Main dairy sources are yogurt and feta cheese

• Red wine with meals

• Olives most days

• Pre and pro biotics for gut heath


4. Which of the following is not specified as a daily recommendation for Mediterranean Diet?

a) Tomatoes

b) Onions

c) Eggplant

d) Wild greens


In addition to a variety of vegetablesInclude leafy greens, onion and/or garlic and

tomatoes daily; fresh or sofrito (tomato based sauce).

• Vegetables significant source of phenolic compounds.

• An abundance of carotenoids, folic acid and fibre (play an important role in CHD prevention).

• Flavonoids have also been associated with improvement in cognitive function and mood (Kinoshita et al. 2005).

• Phytosterols – reduced serum cholesterol and CVD risk (Ortega et al. 2006).

• Garlic onion (herbs and spices) large amounts of flavonoids or allicin –cardiovascular benefits and improvement of cognitive function (Serra Majem et al. 2004).

• High potassium, magnesium and calcium tend to reduce arterial blood pressure (Stark et

al. 2002) (Psaltopoulou et al. 2004).


5. Mediterranean Diet interventions based on traditional principles encompasses what weekly weight of red meat?

a) 60g

b) 120g

c) 200g

d) 240g


Aim for a 4:1 Plant to Animal Food ratio!


Mediterranean Diet Pyramid

Hellenic Dietary Guidelines


Calculating your Mediterranean diet adherence score: The PREDIMED 14-item tool

Martínez-González MA, García-Arellano A, Toledo E, Salas-Salvadó J, et al. (2012) A 14-Item Mediterranean Diet Assessment Tool and Obesity Indexes among High-Risk Subjects: The PREDIMED Trial. PLoS ONE 7(8): e43134. doi:10.1371/journal.pone.0043134http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043134

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043134


Categories of Mediterranean diet adherence

MedDiet adherence Score range

Very low adherence 1-3

Low adherence 4-5

Moderate adherence 6-8

High adherence ≥ 9


Considerations for Application

• Diet and current evidence

• Evidence based practice with multiple comorbidities likely, polypharmacy

• Contradictory dietary advice (e.g. traditionally low fat = fear of ↑ weight and body fat)

• Barriers to intervention adherence

• Lack of motivation (especially in primary prevention)

• Lack of awareness of effect of lifestyle habits on disease and mental health

• Perception of difficult culinary components and eating away from home

• Counselling style

• Patient centred, motivational interviewing, face to face vs phone, individual vs group

• Other factors

• Cultural, time allowed, number of appointments, support (family, friends), SES, food security

APPLICATION

Case StudyMediterranean Diet as an intervention for

chronic disease management


Screening, consent and randomisatio

nMed diet or low fat diet

Face to face appointment - commence intervention

(baseline)

Phone call follow up

(week 3, 6, 9)

Face to face appointment

- mid intervention

(3 month)

Phone call follow up

(month 4, 5)

Face to face appointment

- final intervention

(6 month)

Follow up(12 months)

AUSMED Heart Trial - Study Design

• Clinical questions• Blood sampling• DEXA scan• Anthropometry • Food Diary • Diet counselling

• Diet sustainability • Re-event rate Diagnosed CHD with

• MI, • Stent OR • CABG


Case study – Mrs M.I.

Female, age 53, enrolled February 2015

A: Wt: 88.4 kg, BMI: 33.5 kg/m2, WC: 107.0 cm, DEXA - Total Body fat : 42.9%, Trunk fat : 45.9%

B: Lipids (mmol/L): TC 5.0, LDL 2.6, HDL 1.7, TGs 1.5

Glucose (mmol/L): Fasting 6.1

Inflammatory Marker: hsCRP 2.6 mg/L

BP: 146/100 mmHg

C: MHx: First MI with stent x 3 February 2011, Dx Depression

Meds: Statin, anti-clotting, A2-receptor blocker, Anti-depressant, multi-vitamin, CoQ10, fulvic acid complex

FHx: MI, hypertension, hyperlipidemia

Other:

COB Australia, Parents COB Australia

Non-smoker (never smoked)

Divorced, lives with elderly mother

Works full time at a High school, hour drive to work

Inactive lifestyle: 45 mins moderate activity / week

Seeing Psychologist

One prior session with dietitian for ‘weight loss’ post heart event


Diet at baseline

Meal Food and Drink Choices

Breakfast • Two coffees with full cream milk OR

• Oats sachet with milk and honey OR

• Shortbread biscuit (on the go)

Morning tea Hot chocolate + cake or tart

Lunch • Fried rice and chicken drumbstick OR

• Sushi rolls and hedge hog slice OR

• Canned salmon with green salad, tomato, avocado, olive oil and lemon juice

Afternoon tea Chocolate bar OR cookie OR chocolate coated raisins/nuts

Dinner • Beef casserole (lean beef, vegetables, tomato based, with coconut oil) OR

• Weight watchers spaghetti and meatballs OR

• Roast chicken breast with gravy, peas, mashed potatoes

Supper Berries with ice cream OR fruit bread with blue cheese

Alcohol 2 apple ciders / week

Med diet score = 3/14


Goals set across 6 months

Baseline to 3 months

1. EVOO in cooking (2-3 tbsp. per day)

salad dressing, baked vegetables

Replace use of other oils

Take bottle to work

2. Increase to 2 serves fruit per day

Replace biscuits/cakes with fruit

Include fruit at breakfast with porridge or yoghurt

3. Eat nuts most days

Choose raw nuts instead of chocolate coated

Include in breakfast or as a snack at work

Aim for heart tin at least 3/week

3 to 6 Months

4. Increase to 3 serves fish / week• Fresh fish 1/week • Tinned tuna/salmon at lunch

5. Legumes/lentils in cooking • canned beans in salads/soups/baked dishes

in substitute of red meat • target 1 x 400g can /wk (3 meals)

6. Incorporate wholegrain/low GI cereals• Encouraged incorporating with meals • Choose wholegrain breads/crackers

instead of treat foods


Diet at 6 months

Meal Food and Drink Choices

Breakfast • Greek yoghurt with frozen mixed berries and mixed nuts 4/7

• Porridge from rolled oats 2/7

• Scrambled eggs, soy & linseed bread, mushrooms, tomato, EVOO + coffee 1/7

Morning tea Hot chocolate (low sugar, 1/4 milk)

Lunch • Tinned tuna or salmon, leafy mix, capsicum, cucumber, EVOO and lemon juice (4/7)

• Leftovers – Lentil, chicken or seafood and vegetable soup with bread (3/7)

Afternoon tea Pear OR Muesli bar (fruit and nuts)

Dinner • Lentil, chicken or seafood soup (veg, tomato, garlic, onion) with Soy and linseed bread with EVOO

• Salmon or Mackerel fillet, basmati rice, onion, leafy mix, EVOO, lemon juice

• Pork or steak fillet (lean, 100g), onion relish, bok choy, EVOO

Supper 1 Ferrero rocher OR snickers mini bar OR hot chocolate

Alcohol 1 cider / week, 1 wine / week

Med diet score = 9/14


Macronutrient contribution to Energy

Baseline

CHO 45%

Fat 37%

Protein 16%

Fibre 1.4%

Alcohol 1%

3 Months

CHO 23%

Fat 51%

Protein 21%

Fibre 3%

Alcohol 2%

Energy = 9000 kJ/day Energy = 8000 kJ/day

Fat RatiosMono- 42%Poly- 10%Sat- 48%

Fat RatiosMono- 53%Poly - 26%Sat- 21%


Risk Factors Baseline to 3 months

Risk Marker Baseline 3 Months Anthropometry

Weight (kg)

BMI (kg/m2)

WC (cm)

88.4 33.5107.0

↓ 87.8 ↓ 33.2↓ 103.5

Body composition (DEXA)

% Total body fat

% Trunk fat 42.9 45.9

↓ 42.3 ↓ 44.3

Lipids

LDL (mmol/L)

HDL (mmol/L)

Triglyc. (mmol/L)

2.61.7 1.5

↓ 1.9 ↓ 1.6↓ 1.2

Other Markers

hsCRP (mg/L) 2.6 ↓ 1.8

BP 146/100 ↓124/80


Summary of Mrs M.I. and overall thoughts

• Patient has strong motivation to improve diet + regular follow up

• Sequential, small dietary changes across a long-term intervention

• Ad libitum approach

• High healthy fat intake does not lead to weight gain and reduced WC

• Satiating and sustainable

• Med diet score maintained at 9/14 at 12 month follow up

• Biomarker improvement beyond medications


Overall conclusions

• There are high rates of mental illness throughout chronic disease populations

• Mental illness can have adverse effects on health outcomes, beyond the disease itself

• Inflammation and oxidative stress underpin chronic diseases and mental illness

• Clinicians should be aware of this and have strategies available to enhance treatment outcomes

• Mediterranean diet has been shown to have benefits in a number of chronic diseases

• Evidence is emerging for mood specific outcomes


Acknowledgments

For slides, slide inspiration, collaboration, motivation and sharing the passion.

Our supervisors and colleagues involved in the presented trials.

• Prof Catherine Itsiopoulos

• A/Prof Audrey Tierney

• Dr Colleen Thomas

• Dr Jessica Radcliffe

• Teagan Kucianski

• Anj Reddy

• Our clinical and industry partners.

CONCLUSIONS


Questions?

SMILES Study: presented by Josephine Pizzinga

The SMILES Trial: Reversal of Depression with the ModiMedDiet

Dr Rachelle S Opie


Outline

• The SMILES Trial

• Doctoral aims and objectives

• The modified Mediterranean diet

• Results:

a. Recruitment

b. Dietary improvement

c. Depressive symptomatology

d. Relationship between dietary adherence and depression scores

• Take home messages


The SMILES Trial

Doctoral study was embedded within the SMILES Trial:

• “Supporting the Modification of lifestyle In Lowered Emotional States”

• Randomised controlled trial

• 12-week, parallel group, single blind

• Recruited from the community or ambulatory setting

• Conducted over two sites (St. Vincent’s Health, Collingwood and Barwon Health, Geelong)

SMILES Trial aims:

To investigate the efficacy and cost-efficacy of dietary improvement in the treatment of Major Depressive Episodes (MDE)


The SMILES Trial

Eligible participants were:

• Aged 18 or over

• Successfully fulfilled the DSM-IV-TR diagnostic criteria for Major Depressive Disorders (MDD)

• Scored 18 or over on the Montgomery-ÅsbergDepression Rating Scale (MADRS)

• Current poor quality diets as measured by a Dietary Screening Tool (DST)


The SMILES Trial

Randomisation:

• Control condition (social support / befriending), or

• Dietary intervention (modified Mediterranean diet)

Delivered by an Accredited Practicing Dietitian

Intervention intensity:

• 7 individual sessions (~60 min each), delivered over a 3-month period.

• First 3 sessions occurred weekly, the remaining 4 sessions occurred fortnightly.

Assessments:

• Baseline - prior to program commencement

• 3-months - program completion

• 6-month follow-up (via telephone)


Outcome Measures

Primary Outcome Measure:

• Montgomery-Åsberg Depression Rating Scale (MADRS)

Other Measures:

• Clinical Global Impression Scales (CGI) • Hospital Anxiety Depression Scale (HADS) • Profiles of Mood State (POMS)• WHO well-being index • The Assessment of Quality of Life (AQoL 8D)


Doctoral Study Aims

• To explore whether a dietary intervention, modelled on a

traditional Mediterranean diet and delivered by a

Dietitian, can support individuals with MDD to achieve

improvements in diet quality and nutritional status, and;

• To determine whether dietary improvement can result in

an improvement in depressive symptoms


Doctoral Study Objectives

• To develop, implement and evaluate a modified

Mediterranean diet (“ModiMedDiet”)

• To develop a Mediterranean diet score for assessing diet

quality

• To assess food affordability

• To explore the impact of diet change on depressive

symptomatology


The ModiMedDiet

The ‘modified’ Mediterranean diet (‘ModiMedDiet’) guidelines were:

1. Modelled on the traditional Mediterranean diet

2. Based on scientific evidence from the emerging field of nutritional psychiatric epidemiology

3. Designed specifically for our population group

Primarily constructed using:

• Current evidence regarding the health benefits associated with high adherence to the Mediterranean diet (1,2,3)

• The Australian Dietary Guidelines (4)

• Dietary Guidelines for Adults in Greece (5)

• Australian Government endorsed guidelines relevant to CVD health due to the strong overlap between depression and cardiometabolic conditions (6,7,8).


(C)Designed and

developed by Rachelle Opie

Encompassed a larger variety of foods, which are

commonly consumed in Australia


• Designed to be easy to follow, sustainable, palatable, satiating, practical and considerate of individual circumstances

• Primary focus on increasing diet quality while reducing intake of energy-dense, nutrient poor foods

• Ad libitum. Diet intervention did not have a weight loss focus

NUTRIENT PROFILE

ENERGY ~11MJ per day

HIGH FAT 40% of E (>50% MUFA)

LOW – MODERATE CARBOHYDRATE 36 – 37% of E

MODERATE PROTEIN 18% of E

MODERATE ALCOHOL 2% of E (from red wine)

OTHER fibre/other 3% of E

HIGH FIBRE 50g per day


Incentives

Diet group participants were provided with a food hamper –included the main components of the ModiMedDiet

@ baseline • To encourage dietary adherence

• To display the variety of foods that form the diet

@ trial completion• Incentive for trial completion

• To promote longer-term dietary adherence

Control group were provided with two movie tickets @ trial completion


Food Hamper Contents


Nutritional Counselling Component

o Delivered by APDs

o Resources and Topics:

• dietary guidelines

• convenient meal ideas

• healthy snack options

• shopping lists

• meal plans

• label reading

• recipe modification

• time-management

• food security

o Nutrition Counselling Techniques:

• motivational interviewing (Rollnick S, 1995)

• mindfulness (Kabat-Zin J, 2003)

• goal setting


Dietary Assessment Baseline 12 weeks 6 months

7 day diet diary

Cancer Council FFQ

Diet Quality(dietary screening tool)

Diet history *

Plasma fatty acids

Plasma carotenoids

* Not measured in social support intervention

Measures of Dietary Adherence

Development of the ModiMedDiet Score:

- Criterion-based dietary adherence score

- Comprised of 12 components based on the 12 food groups of the ModiMedDiet

- Accounts for overconsumption of “detrimental” foods

- Out of a theoretical maximum value of 120

Results


Recruitment

o 67 individuals with MDD met eligibility and were randomised to the trial

• Diet intervention, n=33• Social support control, n=34

Groups were well matched on characteristics

Despite randomisation, at baseline, the dietary group had significantly lower scores on the ModiMedDiet score than the control group (p

0.031)


Results: Dietary Improvement Diet Group


Results: Dietary Improvement Control Group

No Change


Discretionary Items

0

5

10

15

20

25

30

35

40

45

Diet Control

Dis

cret

iona

ry It

ems

(mea

n in

take

)

% Energy Intake from Discretionary Items

Baseline 3 month


Results: Depressive Symptoms

MADRS ≥ 18: Moderate to

Severe Depression

MADRS < 10: Remission from

Depression

14.7

20.2

26.1

24.7


Results: Diet Quality and Depression

Highest dietary adherence & Greatest

improvement in depressive symptoms


10 Tips For Success

1. Dietitian delivered • Well resourced - encompass required knowledge and counselling skills

• Lyon Diet Heart Study and PREDIMED Dietitian delivered

2. Moderate intensity • Be aware of clinician and participant burden• Data collection vs patient outcomes

3. Behaviour change intervention with MI and mindfulness

• Information dissemination in isolation is insufficient• MI: client-centred counselling style for eliciting behaviour

change• Help clients explore and resolve ambivalence


4. Be respectful and instil confidence

• Provide a safe, comfortable and relaxing environment • Develop a trusting relationship • Empower the client to feel capable of taking control of

their diet and other aspects of their life

5. Non-judgmental and non-stigmatising

• Listen carefully without assumptions, bias or passing judgement

• Recognise the patient as the expert when it comes to information about his or her experience

6. Individualised and patient-centred care

• Individually tailored to the clients needs and interests• Considerate of individual lifestyle and social

circumstances• Amenable to fluctuations in mood and motivation

10 Tips For Success


10 Tips For Success

7. Goal-orientated • Personalised (and patient centred) SMART goals

8. Easy-to-follow and practical

• Full dietary adherence is unrealistic

• Encourage any positive change

9. Enjoyable and palatable • Address the common cravings for high fat, high sugar and salty foods

10. Food hamper provision • Display the variety of foods that comprise the diet –enhances dietary compliance

SMILES Study – Case Study Example


Baseline Diet Example


References


Take Home Messages

• A healthy modified Mediterranean diet is affordable

• Dietary improvement can be achieved with support from a Dietitian

• Dietary improvement may provide an efficacious and accessible treatment strategy for the management of depressive disorders

• The benefits could extend to the management of common co-morbidities


Acknowledgements

PhD supervisors:

• Professor Catherine Itsiopoulos

• Professor Felice Jacka

• Dr Adrienne O’Neil

Trial staff:

• Josephine Pizzinga

• Sarah Dash

• Melanie Ashton

Dietary Intervention in People with Serious Mental Illness: Scott

Teasdale APD


Scott TeasdaleMental Health DietitianPhD Candidate

Dietary interventions in people with serious mental illness

Thank you:

Special thanks toNatalie (Sinn) Parletta PhD, APD


• Widespread concern for physical health – CVD leading

cause of death.

• Depression top cause of disability, estimated leading

cause of disease by 2030


Serious Mental Illness


Psychotic Disorders


Serious Mental Illness

15-30 YEAR reduced life expectancy for people with

serious mental illness


Estimation of antipsychotic induced weight gain


Antipsychotic Medication Weight gain potential Risk of lipid and/or glucose

disturbance

Chlorpromazine Substantial High (with limited data)

Clozapine Substantial High

Olanzapine Substantial High

Paliperidone Intermediate Mild

Quetiapine Intermediate Moderate

Risperidone Intermediate Mild

Thioridazine Intermediate High (with limited data)

Amisulpride Low Mild

Aripiprazole Low Low

Fluphenazine Low Low (with limited data)

Haloperidol Low Low

Perphenazine Low Low

Ziprasidone Low Low

Reproduced with permission from Blanchard E, Samaras K. Diabetes Management 2014: 4:

339-353. Originally adapted from De Hert 2012 and Foley 2011.

1

Weight & lipid/glucose disturbance potential of APM


Natalie Parletta, Dorota Zarnowiecki, Amy Wilson, Anthony Villani, Catherine Cho, Svetlana Bogomolova, Andrea Fielder, Tom Butler, Nicholas Procter, Kerin O’Dea (UniSA)

John Strachan, Matt Ballestrin, Andrew Champion (Outer South Mental Health Directorate)

Catherine Itsiopoulos (La Trobe University)

Helfimed Program•Nutrition/dietary education

•Cooking workshops – familiarity, exposure, skills

•Food hampers (3 months) based on Mediterranean diet principles

•Shopping vouchers

Bogomolova, Zarnowiecki, Wilson, Procter, Fielder, O’Dea, Strachan, Champion, Ballestrin, Parletta (2016)

105La Trobe UniversityBogomolova et al. (2016)


Nutrition education using food models based on AGTHE

Bogomolova, Zarnowiecki, Wilson, Procter, Fielder, O’Dea, Strachan, Champion, Ballestrin, Parletta (2016)


Mood Study: study design

Treatment group (n=75)-Nutrition education session, goal setting

-Fortnightly cooking workshops for 3 months

-Fortnightly food hampers; shopping/budgeting activities

-Recipes and online resources (website with links, recipes, cooking videos: helfimed.org)

Control group (n=77)-Movie vouchers at each round of assessments

-Fortnightly social groups for 3 months – share holiday stories, play games, personality tests,

sharing of books, watch a movie, etc.; nibbles provided

-Received nutrition education and resources after final assessments

Zarnowiecki , Cho, Wilson, Bogomolova, Villani, Itsiopoulos, Niyonsenga, O’Dea, Segal … Parletta (2016) BMC Nutrition

108La Trobe UniversityBogomolova, Zarnowiecki, Wilson, Procter, Fielder, O’Dea, Strachan, Champion, Ballestrin, Parletta (2016)

HELFIMED Study: Slides removed as paper under review


http://helfimed.org

http://helfimed.org/


Group byDelivered by updated

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Lower Upper g limit limit p-Value

1.00 Cordes, 2014 -0.048 -0.769 0.673 0.8961.00 Scocco, 2005 -0.580 -1.505 0.344 0.2191.00 Kwon, 2006 -0.770 -1.434 -0.107 0.0231.00 Evans, 2005 -1.176 -1.932 -0.421 0.0021.00 Wu, 2007 -1.293 -1.879 -0.708 0.0001.00 Mauri, 2008 -1.339 -2.082 -0.597 0.0001.00 -0.904 -1.217 -0.592 0.0002.00 Goldberg, 2013 0.049 -0.324 0.422 0.7962.00 Iglesias-Garcia, 2010 0.000 -0.981 0.981 1.0002.00 Usher, 2012 -0.049 -0.437 0.338 0.8032.00 Attux, 2013 -0.078 -0.425 0.270 0.6622.00 Lovell, 2014 -0.103 -0.484 0.277 0.5942.00 Brown, 2011 -0.107 -0.520 0.306 0.6122.00 Gillhoff, 2010 -0.210 -0.757 0.338 0.4532.00 Brar, 2005 -0.258 -0.720 0.205 0.2752.00 Littrell, 2003 -0.268 -0.733 0.198 0.2592.00 McKibbin, 2006 -0.440 -0.959 0.078 0.0962.00 Daumit, 2013 -0.463 -0.715 -0.211 0.0002.00 Alvarez-Jimanez, 2006 -0.653 -1.163 -0.142 0.0122.00 Weber, 2006 -0.918 -1.928 0.091 0.0752.00 -0.233 -0.379 -0.088 0.002Overall -0.554 -1.211 0.103 0.098

-2.00 -1.00 0.00 1.00 2.00

Favours nutrition Favours control

Dietary interventions in psychotic disorders

Teasdale et al. Br J Psychiatry, 2017


Active site (KBIM) vs Control site (usual care)

12-week intervention

Metabolic nurse, Dietitian &

Exercise Physiologist

KBIM delivered as part of standard care within

community mental health centre

Curtis et al. Earl Interv Psychiatry, 2015

Keeping the Body In Mind (KBIM) for people living with psychosis


Curtis et al. Early Interv Psychiatry, 2015

% who gained clinically significant weight (>7%)


Case Study: Julio

• 23yo, male

• Inpatient adm following an episode of psychosis

• Diagnosis: BPAD I, mania

• Meds: Olanzapine & Lithium


Case Study: Julio


Kwan et al. J Acad Nutr Diet , 2014


Hearing Voices Activity


Mental health conditions and their nutritional implications

Factors that affect eating and weight gain In people experiencing a mental illness

Medication-nutrient interactions

Medication side effects

Key resources


Mental Health & Nutrition & Dietetics information (MHANDi) Resources

Access through DINER


Key resources

https://www.ranzcp.org/Files/Publications/RANZCP-Serious-Mental-Illness.aspx


Joint Position Statement

https://daa.asn.au/wp-content/uploads/2016/02/Physical-Health-and-Mental-Illness-Joint-Statement.pdf


MIND BODY


Thank you

Dorota Zarnowiecki, Amy Wilson, Jihyun Cho, Svetlana Bogomolova, Anthony Villani, Leonie Segal, Tom Baker, Caitlin Finnis, Sarah Blunden, Catherine Itsiopoulos, Theo Niyonsenga, Kerin O’Dea, NHMRC Program Grant, John Strachan and the Southern Adelaide Local Health Network, Trevor Parry Centre staff & residents, research volunteers

MedLeyMediterranean diet (MedDiet) for cognition and cardiovascular health in the elderly

Jonathan Hodgson, Janet Bryan, Carlene Wilson (NHMRC Project Grant), Richard Woodman, Courtney Davis, Alissa Knight, Kate Dyer, Natalie Blanch, Kristina Petersen, Belinda Hyde, Catherine Yandell, Nerylee Watson, Mark Cutting, Michael Fenech, Varinder Dhillon, Phil Thomas, Paul, Cavuoto, Manohar Garg and our research volunteers.


Thank you

Dr Dorota ZarnowieckiCatherine ChoAmy WilsonDr Svetlana BogomolovaTom ButlerProfessor Nicholas ProcterDr Andrea FielderProfessor Catherine ItsiopoulosProfessor Theo Niyonsenga

Professor Kerin O’DeaProfessor Leonie SegalA/Professor Barbara MeyerProfessor Sarah BlundenOuter South Mental HealthJohn StrachanMatt BallestrinDr Andrew ChampionTPC Staff and Residents

NHMRC Program Grant funding

Website for Workshop Slides and Resources:

http://www.latrobe.edu.au/rehabilitation-nutrition-and-

sport/research/food-for-life-collaborative-research

how to better your mood with healthy food! · we eat 3kg of food and beverages each day and 35% of...

Documents