A Systematic Review to Propose an Evidence-based Nutrition Protocol in Depression

Background: Rates of depression have been rising steadily over the last several decades with more than 264 million people affected, making it one of the top three burdens globally. The pandemic has brought on a greater risk of depression. Forty-two percent of individuals surveyed in December 2020 by the US Census Bureau reported depressive symptoms. Many factors, including poor diet quality, play a role in the development of depression during traumatic events like the pandemic. A low-quality dietary pattern has been associated with obesity, low-grade chronic inflammation, dysbiosis, increased cortisol levels and monoamine neurotransmitter deficiency. Among others, these factors have been correlated with an increased risk of depression. Additionally, antidepressants have been shown to be ineffective in up to 40% of individuals. Therefore, the potential of a nutrition-focused approach could be helpful. Purpose/Objectives: A systematic review was conducted to determine if an evidence-based, targeted nutrition protocol could be developed for the prevention or treatment of depressive symptoms. Methods: The systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and PICOS framework. An extensive PubMed search was conducted in June 2021. Randomized control trials or observational studies published in 2005 or later with human adults 18 or older that consisted of a dietary pattern or nutrition intervention, depression outcome measured and similar group treatment were reviewed for inclusion. Results: The Mediterranean-style and anti-inflammatory dietary patterns were associated with the greatest improvements by potentially mitigating oxidative stress and systemic inflammation associated with depression. Supplementation of certain nutrients including B vitamins, vitamin D, omega-3 fatty acids, zinc, or magnesium were associated with a decrease in depressive symptoms. Conclusions: The results of nearly 100 studies strongly indicate certain nutrients and dietary patterns have the potential to reduce depressive symptoms. A proposed nutrition protocol was developed as a result of this unique review. Interprofessional Implications: Proper nutrition has a significant impact on overall health and reduced risk of disease, likely from the potential to modulate pathophysiological factors in depression. The use of a targeted nutrition-focused protocol could be useful in the prevention or treatment of mental illness. Abstract References: Adaa.org. Accessed June 1, 2021. https://adaa.org/understanding-anxiety/depression Abbott A. COVID’s mental-health toll: how scientists are tracking a surge in depression. Nature. 2021;590(7845):194-195. Pham KM, Pham LV, Phan DT, et al. Healthy Dietary Intake Behavior Potentially modifies the negative effect of COVID-19 lockdown on depression: A hospital and health center survey. Front Nutr. 2020;7:581043. Published 2020 Nov 16. doi:10.3389/fnut.2020.581043 Slyepchenko A, Maes M, Jacka FN, et al. Gut microbiota, bacterial translocation, and interactions with diet: Pathophysiological links between major depressive disorder and non-communicable medical comorbidities. Psychother Psychosom. 2017;86(1):31-46. doi:10.1159/000448957 Tryon MS, Stanhope KL, Epel ES, et al. Excessive sugar consumption may be a difficult habit to break: A view from the brain and body. J Clin Endocrinol Metab. 2015;100(6):2239-2247. doi: 10.1210/jc.2014-4353 Al-Dujaili EAS, Ashmore S, Tsang C. A short study exploring the effect of the glycaemic index of the diet on energy intake and salivary steroid hormones. Nutrients. 2019;11(2):260. doi: 10.3390/nu11020260 Parletta N, Zarnowiecki D, Cho J, et al. A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: A randomized controlled trial (HELFIMED). Nutr Neurosci. 2019;22(7):474-487. doi:10.1080/1028415X.2017.1411320 Jacka FN, O\u27Neil A, Opie R, et al. A randomised controlled trial of dietary improvement for adults with major depression (the \u27SMILES\u27 trial) [published correction appears in BMC Med. 2018 Dec 28;16(1):236]. BMC Med. 2017;15(1):23. Published 2017 Jan 30. doi:10.1186/s12916-017-0791-y Wade AT, Davis CR, Dyer KA, et al. A Mediterranean diet supplemented with dairy foods improves mood and processing speed in an Australian sample: results from the MedDairy randomized controlled trial. Nutr Neurosci. 2020;23(8):646-658. doi:10.1080/1028415X.2018.1543148 Sánchez-Villegas A, Martínez-González MA, Estruch R, et al. Mediterranean dietary pattern and depression: the PREDIMED randomized trial. BMC Med. 2013;11:208. Published 2013 Sep 20. doi:10.1186/1741-7015-11-208 Veronese N, Stubbs B, Noale M, Solmi M, Luchini C, Maggi S. Adherence to the Mediterranean diet is associated with better quality of life: data from the Osteoarthritis Initiative. Am J Clin Nutr. 2016;104(5):1403-1409. doi:10.3945/ajcn.116.136390 Skarupski KA, Tangney CC, Li H, Evans DA, Morris MC. Mediterranean diet and depressive symptoms among older adults over time. J Nutr Health Aging. 2013;17(5):441-445. doi:10.1007/s12603-012-0437-x Sánchez-Villegas A, Henríquez-Sánchez P, Ruiz-Canela M, et al. A longitudinal analysis of diet quality scores and the risk of incident depression in the SUN Project. BMC Med. 2015;13:197. Published 2015 Sep 17. doi:10.1186/s12916-015-0428-y Sánchez-Villegas A, Delgado-Rodríguez M, Alonso A, et al. Association of the Mediterranean dietary pattern with the incidence of depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN) cohort. Arch Gen Psychiatry. 2009;66(10):1090-1098. doi:10.1001/archgenpsychiatry.2009.129 Calderón-Ospina CA, Nava-Mesa MO. B Vitamins in the nervous system: Current knowledge of the biochemical modes of action and synergies of thiamine, pyridoxine, and cobalamin. CNS Neurosci Ther. 2020;26(1):5-13. doi: 10.1111/cns.13207 Aly J, Engmann O. The way to a human\u27s brain goes through their stomach: dietary factors in major depressive disorder. Front Neurosci. 2020;14:582853. Published 2020 Dec 7. doi:10.3389/fnins.2020.582853 Al-harbi. Treatment-resistant depression: therapeutic trends, challenges, and future directions. Patient Prefer Adherence. Published online 2012:369. doi: 10.2147/PPA.S29716 Shivappa N, Schoenaker DA, Hebert JR, Mishra GD. Association between inflammatory potential of diet and risk of depression in middle-aged women: the Australian Longitudinal Study on Women\u27s Health. Br J Nutr. 2016;116(6):1077-1086. doi:10.1017/S0007114516002853 Lucas M, Chocano-Bedoya P, Schulze MB, et al. Inflammatory dietary pattern and risk of depression among women [published correction appears in Brain Behav Immun. 2015 May;46:327. Shulze, Mathias B [corrected to Schulze, Matthias B]]. Brain Behav Immun. 2014;36:46-53. doi:10.1016/j.bbi.2013.09.014 Adjibade M, Andreeva VA, Lemogne C, et al. The inflammatory potential of the diet is associated with depressive symptoms in different subgroups of the general population. J Nutr. 2017;147(5):879-887. doi:10.3945/jn.116.245167 Phillips CM, Shivappa N, Hébert JR, Perry IJ. Dietary inflammatory index and mental health: A cross-sectional analysis of the relationship with depressive symptoms, anxiety and well-being in adults. Clin Nutr. 2018;37(5):1485-1491. doi:10.1016/j.clnu.2017.08.029 Bergmans RS, Malecki KM. The association of dietary inflammatory potential with depression and mental well-being among U.S. adults. Prev Med. 2017;99:313-319. doi:10.1016/j.ypmed.2017.03.016 Adjibade M, Lemogne C, Touvier M, et al. The inflammatory potential of the diet is directly associated with incident depressive symptoms among French adults. J Nutr. 2019;149(7):1198-1207. doi:10.1093/jn/nxz045 Loria-Kohen V, Gómez-Candela C, Palma-Milla S, Amador-Sastre B, Hernanz A, Bermejo LM. A pilot study of folic acid supplementation for improving homocysteine levels, cognitive and depressive status in eating disorders. Nutr Hosp. 2013;28(3):807-815. doi:10.3305/nh.2013.28.3.6335 de Koning EJ, van der Zwaluw NL, van Wijngaarden JP, et al. Effects of two-year vitamin B12 and folic acid supplementation on depressive symptoms and quality of life in older adults with elevated homocysteine concentrations: Additional results from the B-PROOF Study, an RCT. Nutrients. 2016;8(11):748. Published 2016 Nov 23. doi:10.3390/nu8110748 Gougeon L, Payette H, Morais JA, Gaudreau P, Shatenstein B, Gray-Donald K. Intakes of folate, vitamin B6 and B12 and risk of depression in community-dwelling older adults: the Quebec Longitudinal Study on Nutrition and Aging. Eur J Clin Nutr. 2016;70(3):380-385. doi:10.1038/ejcn.2015.202 Kaviani M, Nikooyeh B, Zand H, Yaghmaei P, Neyestani TR. Effects of vitamin D supplementation on depression and some involved neurotransmitters. J Affect Disord. 2020;269:28-35. doi:10.1016/j.jad.2020.03.029 Mozaffari-Khosravi H, Nabizade L, Yassini-Ardakani SM, Hadinedoushan H, Barzegar K. The effect of 2 different single injections of high dose of vitamin D on improving the depression in depressed patients with vitamin D deficiency: a randomized clinical trial. J Clin Psychopharmacol. 2013;33(3):378-385. doi:10.1097/JCP.0b013e31828f619a Jamilian M, Samimi M, Mirhosseini N, et al. The influences of vitamin D and omega-3 co-supplementation on clinical, metabolic and genetic parameters in women with polycystic ovary syndrome. J Affect Disord. 2018;238:32-38. doi:10.1016/j.jad.2018.05.027 Raygan F, Ostadmohammadi V, Bahmani F, Asemi Z. The effects of vitamin D and probiotic co-supplementation on mental health parameters and metabolic status in type 2 diabetic patients with coronary heart disease: A randomized, double-blind, placebo-controlled trial. Prog Neuropsychopharmacol Biol Psychiatry. 2018;84(Pt A):50-55. doi:10.1016/j.pnpbp.2018.02.007 Ostadmohammadi V, Jamilian M, Bahmani F, Asemi Z. Vitamin D and probiotic co-supplementation affects mental health, hormonal, inflammatory and oxidative stress parameters in women with polycystic ovary syndrome. J Ovarian Res. 2019;12(1):5. Published 2019 Jan 21. doi:10.1186/s13048-019-0480-x Rajizadeh A, Mozaffari-Khosravi H, Yassini-Ardakani M, Dehghani A. Effect of magnesium supplementation on depression status in depressed patients with magnesium deficiency: A randomized, double-blind, placebo-controlled trial. Nutrition. 2017;35:56-60. doi:10.1016/j.nut.2016.10.014 Yary T, Lehto SM, Tolmunen T, et al. Dietary magnesium intake and the incidence of depression: A 20-year follow-up study. J Affect Disord. 2016;193:94-98. doi:10.1016/j.jad.2015.12.056 Solati Z, Jazayeri S, Tehrani-Doost M, Mahmoodianfard S, Gohari MR. Zinc monotherapy increases serum brain-derived neurotrophic factor (BDNF) levels and decreases depressive symptoms in overweight or obese subjects: a double-blind, randomized, placebo-controlled trial. Nutr Neurosci. 2015;18(4):162-168. doi:10.1179/1476830513Y.0000000105 Sawada T, Yokoi K. Effect of zinc supplementation on mood states in young women: a pilot study. Eur J Clin Nutr. 2010;64(3):331-333. doi:10.1038/ejcn.2009.158 Park Y, Park YS, Kim SH, Oh DH, Park YC. Supplementation of n-3 polyunsaturated fatty acids for major depressive disorder: A randomized, double-blind, 12-week, placebo-controlled trial in Korea. Ann Nutr Metab. 2015;66(2-3):141-148. doi:10.1159/000377640 Rondanelli M, Giacosa A, Opizzi A, et al. Long chain omega 3 polyunsaturated fatty acids supplementation in the treatment of elderly depression: effects on depressive symptoms, on phospholipids fatty acids profile and on health-related quality of life. J Nutr Health Aging. 2011;15(1):37-44. doi:10.1007/s12603-011-0011-y Duffy SL, Lagopoulos J, Cockayne N, et al. The effect of 12-wk ω-3 fatty acid supplementation on in vivo thalamus glutathione concentration in patients at risk for major depression. Nutrition. 2015;31(10):1247-1254. doi:10.1016/j.nut.2015.04.019 Yang B, Lin L, Bazinet RP, et al. Clinical efficacy and biological regulations of ω-3 PUFA-derived endocannabinoids in major depressive disorder. Psychother Psychosom. 2019;88(4):215-224. doi:10.1159/000501158 Jamilian M, Shojaei A, Samimi M, et al. The effects of omega-3 and vitamin E co-supplementation on parameters of mental health and gene expression related to insulin and inflammation in subjects with polycystic ovary syndrome. J Affect Disord. 2018;229:41-47. doi:10.1016/j.jad.2017.12.049 Sinn N, Milte CM, Street SJ, et al. Effects of n-3 fatty acids, EPA v. DHA, on depressive symptoms, quality of life, memory and executive function in older adults with mild cognitive impairment: a 6-month randomised controlled trial. Br J Nutr. 2012;107(11):1682-1693. doi:10.1017/S0007114511004788 van de Rest O, Geleijnse JM, Kok FJ, et al. Effect of fish-oil supplementation on mental well-being in older subjects: a randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2008;88(3):706-713. doi:10.1093/ajcn/88.3.70