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Alex Raben: [00:00:00] Hey, listeners, it's Alex here. I just wanted to say how excited we are to have our very first episode coming out of Montreal. This episode on nutritional psychiatry was led by Sarah Hanafi. Sarah works tirelessly behind the scenes as our head of research, and we really appreciate all she does for PsychEd. I hope you'll learn as much about this important and often neglected topic in psychiatry as I did. Enjoy.
Sarah Hanafi: [00:00:36] Welcome to PsychEd, the Educational Psychiatry Podcast for Medical Learners by Medical Learners. In today's episode, we're going to be covering the topic of nutritional psychiatry. My name is Sarah Hanafi and I'm a PGY2 in psychiatry at McGill University. We're very happy to be joined today by Dr. Laura LaChance, who is a psychiatrist at Saint Mary's Hospital here in Montreal.
Nima Nahiddi: [00:00:59] My name is Nima Nahiddi, and I'm also a Pgy2 psychiatry resident at McGill University.
Gray Meckling: [00:01:06] And my name is Gray Meckling, and I'm a third-year medical student at University of Toronto.
Sarah Hanafi: [00:01:11] By the end of this episode, we're hoping that you'll be able to have a better understanding of how we define nutritional psychiatry, that you also develop an understanding of the mechanisms, common misconceptions, challenges and current evidence supporting the role for nutrition in mental health and finally, that you'll be able to apply this understanding to clinical cases in psychiatry.
Nima Nahiddi: [00:01:44] So to start off, Dr. LaChance, we're so happy you can be here with us, although here is virtually. Can you let us know a bit about your professional background before we start?
Dr Laura LaChance: [00:02:00] Sure. So thanks so much, guys, for having me on the podcast today. And you know, I know we were having some scheduling difficulties and Covid obviously didn't help and at a certain point you just need to get on with learning activities, so I'm glad we're able to make this happen. So I'm a psychiatrist. I work at Saint Mary's Hospital, which is a McGill affiliated hospital in Montreal, and my clinical practice right now is in general psychiatry, so I work with patients in the emergency room and the outpatient clinic. I'm also newly the director of outpatient psychiatry here at Saint Mary's and the my focus right now is actually on working in the Mental Health Crisis Clinic so I work with a lot of transitional aged youth in particular through that clinic. So that's kind of what I'm doing now clinically. Um, you know, where does that place me in relation to nutritional psychiatry? So this is my research interest. I graduated from the University of Toronto in 2017 residency program in psychiatry and, as part of my residency I did a fellowship, a research fellowship in the social determinants of mental health and there I focused on nutrition and food insecurity as determinants of mental health. And so that kind of, you know, early on informed my research interest in the field. And I've been doing research in this field since about 2012, I would say. Um, so yeah, I guess we'll get more into specifics. Um, but I'll just add, I'm also doing my Masters in psychiatry right now, so I kind of have a few different hats that I'm wearing.
Gray Meckling: [00:03:33] Okay. Thank you so much, Dr. LaChance, for sharing some of your background. So I think to jump things off in the episode, we're going to just ask if you could define nutritional psychiatry for our listeners.
Dr Laura LaChance: [00:03:47] Yeah, it's a good question and there are a bunch of different definitions floating around if you Google it. So what I choose, the definition that I choose to stick with is nutritional psychiatry is basically integrating nutritional approaches into both the prevention and the treatment of mental disorders and their comorbidities.
Gray Meckling: [00:04:08] Okay. And so that's one question that I had starting this episode, was whether or not the nutritional interventions are really just looking at the mental health disorders or if they're also addressing things like metabolic syndrome that can happen to people who have mental health diagnoses.
Dr Laura LaChance: [00:04:29] I mean, I think it's both because, you know, you're obviously going to have some side effects, quote unquote, of your nutritional interventions, which are going to be impacts on physical health as well. And we know that our patient population has high rates of metabolic illness, cardiovascular illness, so you can't really separate the two.
Gray Meckling: [00:04:47] Yeah. And so being a medical student, this was definitely a new field of psychiatry that I've just been exposed to. Could you maybe walk us through sort of the origin or the history of nutritional psychiatry as a field?
Dr Laura LaChance: [00:05:02] Um, well, I mean, it's interesting because we think that nutritional psychiatry is this new field and, you know, the whole kind of concept of food as medicine is getting a lot of attention and, you know, all the health blogs in the general population and obviously in scientific research as well. And um, when you look at the scientific literature, there are actually a ton, there's been a ton of research in nutritional psychiatry kind of even predating our medications. So I did a meta-analysis of, um, biomarkers of gluten sensitivity in individuals with schizophrenia in 2014 and the reason I mentioned that is because there were research papers where psychiatrists were looking at biomarkers of gluten sensitivity in that patient population schizophrenia back in the 1960s. And so like, you know, they had randomised controlled trials in the, in the standards that were, you know, typical of research at the time where they randomised one psychiatry inpatient unit to a gluten free and a casein free, which is the milk protein, one of the milk proteins that's most likely to cause an allergic reaction. So they had milk free, wheat free, um, wards versus wards that got just like the regular control diet and then they measured psychiatric symptoms and time to discharge, yeah and this is the 60s. And you know, another example would be like Orthomolecular psychiatry, which I couldn't actually put a date on that but the person who most closely comes to mind is Linus Pauling and high doses of vitamin C to treat a number of conditions, including psychiatric conditions. And this is all, you know, really, these are all really old ideas. And so I think nutritional psychiatry was actually popular, um, you know, more than 50 years ago, but is now seeing a resurgence really in the last ten years or so I would say.
Sarah Hanafi: [00:06:55] It's really helpful to hear that background and get a better sense of what, where or where this field has kind of come from in the past few decades. Um, you know, I know for myself, I've heard of terms like inflammation and the immune system is, is possibly explaining some of the link between mental health and nutrition as well as concepts like oxidative stress and the microbiome gut brain axis. I'm wondering if maybe you could touch briefly on some of the mechanisms we're starting to think are involved in the relationship between nutrition and mental health.
Dr Laura LaChance: [00:07:37] For sure, and I'll try my best to be brief on these because each one could be, you know, a podcast in and of itself. So when we think about the different mechanisms that underlie the links between nutrition and mental health, before we get into it, I just want to emphasise that it's a bidirectional relationship. So, you know, we're talking today about how nutrition can impact mental health, but obviously the reverse is also a very important relationship to consider, so how having a mental disorder or your mental health can impact your nutrition. And so kind of taking a step back, like thinking about things like food insecurity, how mental health disorders can impact, you know, appetite, how our psychiatric medications can impact appetite and how that impacts eating behaviour. You know, obviously eating disorders is kind of a separate entity that's beyond the scope of today but so just kind of before we get into the science, looking at, you know, nutrition impacting mental health, just recognising that this is obviously complex and bidirectional.
Dr Laura LaChance: [00:08:37] Um, but so with that, so thinking about mechanisms, so inflammation is certainly one of the, one of the important mechanisms, explaining how nutrition can impact mental health and inflammation is an area of research in psychiatry that's gaining a lot of traction recently. So, you know, a number of meta-analyses have found that there are heightened number, heightened levels of peripheral biomarkers of inflammation, so things like inflammatory cytokines, um, interleukins, TNFs, CRP, you know, those types of molecules in bipolar disorder, in depression unipolar in schizophrenia and we also know that, you know, when we think about the comorbidities that our patients often are diagnosed with like metabolic disorders, cardiovascular disorders, we know that inflammation plays a role there, too. So this is a really important topic and I think for today we're interested in understanding what does diet have to do with this. So try to kind of break it down. So we know there are certain foods or dietary factors that tend to promote inflammation, so those are things like refined carbohydrates, ultra processed foods and also sugar. There are also dietary factors that tend to reduce inflammation so things like vegetables, fruits, fibre, so legumes are examples of sorts of sources of fibre, whole grains, healthy fats like omega-3s or monounsaturated fats and also fermented foods. And so when I'm describing kind of the factors that tend to either promote inflammation or reduce inflammation, I'm describing a dietary pattern that maps pretty closely onto the Mediterranean diet. And, you know, it hasn't been shown yet in psychiatric populations. But if looking at other clinical populations, there's a recent meta-analysis of 50 experimental studies that found that Mediterranean diet can reduce biomarkers of inflammation. So, you know, that's kind of one way of thinking about it as from like a dietary pattern perspective.
Dr Laura LaChance: [00:10:45] We can also break it down so we can look at, for instance, the balance of omega-6 and omega-3 in the diet. So those are two types of fatty acids that are they make up a minority of the amount of total fat that we eat. But in recent years with, you know, how agriculture and the food processing industry has changed, we've seen really major shifts in the amount of relative omega-6 and omega-3 that we consume today relative to 100 years ago. And omega-6 fatty acids tend to be pro-inflammatory, whereas omega-3s are anti-inflammatory. So that kind of imbalance that we see in the diet is another way that diet ties to inflammation. And then the microbiome is implicated there too but I think I'll save that for a bit later.
Sarah Hanafi: [00:11:32] Fair enough.
Dr Laura LaChance: [00:11:33] So yeah, because we'll get to that. There's a lot of overlap.
Nima Nahiddi: [00:11:38] It's really fascinating, this idea of the bidirectionality between, you know, nutrition and then some of, you know, implications of mental health. Do you think that there's common misconceptions about things that are happening in, you know, mental health and the role that nutrition can have? Maybe things that are in the media or things that physicians might think of that could be common misconceptions?
Dr Laura LaChance: [00:12:19] Yeah. So the first misconception that comes to mind is the idea that mental health and nutrition are not related, or that somehow nutrition is not important for mental health. And I'm obviously an early career psychiatrist, but I would say earlier in my career, that's the one that I was really pushing up against. And so every time I would give talks or presentations or whatever, it was always kind of like, you know, newsflash, nutrition is important for mental health, whereas now I find that's already become, um, you know, sort of accepted, at least relative to where things were about five years ago. Um, so I'm happy that there's a growing recognition now that food is medicine and that psychiatry is part of medicine, so that one is a little bit less relevant. What I'm seeing a lot now in terms of misconceptions is this idea around helping psychiatric patients to change their diet is not feasible, in some way, or that it's futile. You know, there's always something else that's higher priority than talking about diet and so I have some thoughts about about that if you guys are interested.
Nima Nahiddi: [00:13:30] Yeah. What is it that that you think is the greatest barrier?
Dr Laura LaChance: [00:13:34] Well, I mean, we know that nutrition is not a huge part of medical training. So there's definitely a piece around lack of knowledge, um, for like perceived lack of knowledge for health care providers. But I don't think you need to have a graduate degree in nutrition to be able to counsel your patients on diet because, you know, we all prepare food for ourselves and eat every day. Um, so, you know, I think it, I think it's more like some kind of barrier that, that we've put up based on, um, you know, what our comfort level is or what like we learned from observing other clinicians. So, you know, other clinicians aren't talking about food, so, so we shouldn't like, I don't, I don't think that there's, um, I don't think it's anything really more complicated than that. And, you know, I see that we talk to our patients about all kinds of stuff. We talk about substance use, we talk about, you know, finances, their innermost private thoughts, past trauma, their sexuality, you know, everything. And so why why would it not be appropriate to also talk about food?
Dr Laura LaChance: [00:14:42] And then, you know, when you think about who is best suited to help psychiatric patients to make these often basic changes in their diet, I think we actually, as mental health professionals, have a lot of tools at our disposal to help our patients make behaviour change because, you know, that's what we do, whether it's sleep hygiene, taking medication, you know, engaging in psychotherapy. Um, so I mean, I think we're actually well suited and, you know, often patients are coming to us with like, okay, well what can I do to take care of myself at this early stage while I'm waiting for the medication to take effect? Or families are asking us, what can I do to support my loved one who's struggling with depression? Well, I think actually preparing healthy food for yourself or your family member is something tangible that we can do that gives some direction to families and patients. And I think we have to remember that these interventions are also very safe. So, you know, I talked earlier about side effects of dietary interventions being possibly improved physical health. And so, yeah, I think we need to kind of take that into consideration as well as we're like, you know, waiting for the perfect research to to guide us in terms of making recommendations for our patients.
Nima Nahiddi: [00:15:52] And being mental health professionals, do you have or can you discuss a bit about some of the research and some of the evidence supporting the role of nutrition in the management of psychiatric illnesses?
Dr Laura LaChance: [00:16:08] Yeah. So, um so I think it makes sense to probably focus a little bit here just because it's hard to give like a broad overview of everything. But if I take depression for an example, which is a condition that like anyone's going to treat, and it's also the condition that has the most advanced literature in terms of nutritional psychiatry. So depression, so there's at least three randomised controlled trials now of dietary interventions in depression, like clinically significant major depressive disorder, and they're all a little bit different. So one was an individual intervention of a mediterranean diet. One was a group intervention of a mediterranean diet with supplemental omega-3, and the other was basically a video with two five-minute follow up phone calls and some information on FAQs and like tips and recipes. And all three of those studies found that the Mediterranean diet, as compared to a control intervention, significantly reduced depressive symptoms. And so these are these are add-on treatments, I think that's an important point that you know nobody's recommending that you don't offer you know the gold standard treatments that we have but it's just like something benefit something additionally that's beneficial because we don't like you know we don't have 100% remission rate for depression with our current treatments.
Nima Nahiddi: [00:17:40] And as you said, the side effects, the side effects are or can be safe when it comes to nutritional interventions.
Dr Laura LaChance: [00:17:51] Yeah, exactly and another sort of piece of literature, so there's, there's been a shift in the field where initially there was a lot more emphasis on studying individual nutrients or individual foods. And then in recent years, to say the last ten years or so, people have been talking a lot more in the literature about dietary patterns and understanding which dietary patterns can either increase risk or decrease risk of depression or be used as treatment. And so a couple of years ago, probably for I don't know, honestly, I think was in PGY2 when I first came up with this idea, um I was wondering okay, so there are these dietary patterns which seem to be helpful for depression, but what are the actual active ingredients here? Like, if somebody wanted to actually design a diet that was going to promote recovery from depression, what foods would be included in that? So I partnered with Dr. Drew Ramsey, who's a nutritional psychiatrist in New York and runs the brain food clinic there, and we conducted a literature review to identify what are the, what are the, we call them "antidepressant nutrients", so which nutrients have the highest level of evidence to support their role in either prevention or treatment of depression? And then we took this list of antidepressant nutrients, and we applied a nutrient density formula and then tried to identify what are the foods that actually have the highest nutrient density of these antidepressant nutrients. And we looked at individual foods, we looked at food categories and the findings were super interesting to me because the foods that came up on top were, you know, leafy greens, seafood, organ meats, other vegetables, fruits and it was really foods that are highly prevalent in traditional diets from a number of different cultures, but certainly foods that are not common in the Western diet. So it was like another, you know, kind of coming at it from coming at the question from a completely different angle and then finding the same answer.
Nima Nahiddi: [00:20:00] And so do you think with the dietary patterns, you know, we should be looking into making new diets with these types of foods in them?
Dr Laura LaChance: [00:20:11] Well, not necessarily. I mean, I think what's interesting about the findings is that I think that they could be like the foods that came up on top could be integrated into any dietary pattern that that's fitting with your culture and preferences. So, you know, like seafood came up on top, for instance and like, depending on what your culture is and what your preference is, you could choose different kinds of seafood. I mean, you know within reason, I think it's I think it's reasonable to sort of shift towards, you know, maybe a certain food that may have a higher nutrient density than another, but I don't think anybody, you know, I think compliance would be a problem if you if you try to be too prescriptive with any diet.
Nima Nahiddi: [00:20:55] Yeah, I can imagine that that would be it would be difficult. Compliance would be difficult with any diet and I think we see that in with a lot of different people. Um, do you have any, any evidence about you talked about omega-3 versus omega-6. Have there been any, any evidence or any studies about those and their roles in the management of mental health disorders?
Dr Laura LaChance: [00:21:26] Mhm. So, um Omega-3s so again, there's probably the most literature in, in depression, although there's a decent smattering of literature in schizophrenia as well, although probably a bit more controversial. So in depression, if you look to the most recent CANMAT guidelines,so C-A-N-M-A-T, which are the guidelines that we typically refer to in Canada to um, you know, guide us in terms of treating depression, omega-3s are listed there as second line evidence, as either monotherapy or as adjunctive therapy. Um, and the International Society for Nutrition and Psychiatry Researchers published in September 2019 a series of specific guidelines for using omega-3s in depression. So basically what's been shown is that for both bipolar depression and unipolar depression, there's there's multiple, you know, 15 plus RCTs to support use of omega-3s as adjunctive treatment. If you have mild depression, you can start with just omega-3s as monotherapy, so by themselves and it's more important that the omega-3s contain a higher dose of EPA relative to DHA, and those are the two long chain fatty acids that are the most bioavailable and usable by the brain. So you want to look for a dose of EPA somewhere between 1 and 2g, so 1000 to 2000mg and depending on which supplement you're taking, that might actually involve taking more than one of those little gels, so you have to read carefully on the label, but that's the dose for acute treatment. And then if you're more in like a maintenance kind of brain health, then you can then it's okay to use to use lower doses, similar as with medication. We have doses for acute treatment and then doses that we would use for maintenance.
Nima Nahiddi: [00:23:18] Similar to any other type of medication.
Dr Laura LaChance: [00:23:21] Yeah. So I treat it as such. And it's the same kind of thing, right? I'll start the omega-3s, you know, assess tolerability at two weeks, think about maximising the dose based on tolerability, wait 4 to 6 weeks to see an effect. You know, same same kind of principles.
Gray Meckling: [00:23:35] So we've been discussing some of the research around nutritional psychiatry. I think the next section we wanted to touch on was really tie things back to clinical practice. And so I'm wondering if you can take us through maybe a common clinical case that might demonstrate some of these principles. For example, one that I saw in the literature and I'm sure there are many others, would be something like iron deficiency and how that may relate to depression.
Dr Laura LaChance: [00:24:02] Sure. So so I mean, I can think of a number of cases. So what I'll share with you is probably just like a bit of a fusion of several individuals. But I tend to think of iron deficiency when I see somebody who's presenting with depression, who has decreased food intake for whatever reason, it may be due to their depression itself as a symptom or there may be other reasons like, you know, food insecurity, dietary preferences, they're restricting a bunch of different kinds of foods and as part of our usual workup for depression, we should be doing a CBC. But I think that in certain, if you have certain risk factors, like somebody who's vegetarian, a woman who's of in their reproductive years, you know, decreased intake for another any other reason I always add on a ferritin with that first CBC that I order because you can see early signs of iron deficiency even before the person becomes frankly anaemic. And often when you think about symptoms, often the person's presenting with cognitive difficulties and low energy, right? A lot of fatigue in in context of their depression. And then I'll basically include adjunctive treatment with an iron supplement as part of the treatment. And I'll also counsel my patients around iron rich foods to increase into their diet.
Gray Meckling: [00:25:34] Right, and so have you seen this play out in any of your patients where prescribing the iron or the ferrous sulphate as an adjunctive treatment has really shown an improvement in their symptoms beyond maybe the standard of care?
Dr Laura LaChance: [00:25:49] Yeah, I mean, I've seen I've seen it a few times. I've presented a few cases at our clinical rounds, which feels like an eternity ago, which was in April. But one person stands out in particular. She's the young woman with bipolar depression and she she looked kind of iron deficient to me. She just looked so tired all of a sudden and she was complaining a lot of low energy, and it was really a change from her mental status before. And she had been following a diet that was, um, like it wasn't vegetarian per se, but she was really focused on weight loss and so her main protein source was chicken breast and a lot of just like basic salads and stuff like that. So her actual intake of iron is down and she's a menstruating woman and she was iron deficient. And so I added that to her treatment for depression. Um, you know, I would never, like if somebody has symptoms of depression, I would never deprive them from the normal, you know, standard of care treatment. So it's challenging in nutritional psychiatry because you never have the situation where you're just treating somebody with a dietary intervention. Um, but, you know, she responded really well and I could see the improvements in her mental status track with, with her ferritin levels normalising. So I mean it's, it's challenging because you don't really have you know, you can't say what did what with 100% certainty. Um but I have been seeing definitely a pattern in my clinical practice.
Gray Meckling: [00:27:26] Yeah, that's great. And it sounds like it can be really important to watch out for these nutritional deficiencies or other dietary factors that may be contributing to people's mental health challenges. One question related to this is I'm wondering if you think most psychiatrists are comfortable prescribing these types of dietary or supplemental interventions.
Dr Laura LaChance: [00:27:53] I think the supplements are a little bit trickier. They're also higher risk. For instance, you wouldn't want to indefinitely prescribe somebody an iron supplement because, you know, you can have toxicity from having too much iron. You know, similarly, if you took four grams of EPA, you know, every day for the rest of your life, maybe you'd be at increased risk of bleeding, for instance. So the supplements are a little bit trickier. So I think we do need to, you know, lean on guidelines, for instance, like the guidelines I mentioned for the omega-3 supplements in depression or looking to clinical, you know, point of care resources like UpToDate to understand how to prescribe iron supplementation for iron deficiency. But I think that the food interventions, I think the beauty of the actual nutritional interventions is that they have such a better safety profile. So really, I think that any doctor, you know, can feel comfortable and I can get into kind of more specifics of how do I assess diet and what do I recommend if that's of interest?
Gray Meckling: [00:28:54] I think maybe for now we can just put a flag in that point, because I wanted to quickly ask you also about psychotic disorders and if there's any evidence or any clinical cases that you can think of that might relate to diet and any of the psychotic disorders.
Dr Laura LaChance: [00:29:12] Yeah. So I published a scoping review on that topic about a year ago and so there is there is a very, you know, plentiful body of research on this topic and I think it speaks to the fact that we still don't really understand schizophrenia very well. The treatments we currently have are limited so it's one of those disorders where, you know, pick a theory and somebody studied it 50 years ago because it's just like, you know, we just really don't, we have more questions than answered than answers. But so for for psychotic disorders, I mean, where to start? So certainly we know from observational literature that individuals who have schizophrenia spectrum disorders follow a lower quality diet than the general population and kind of just summarise it at that. There's a large body of research on omega-3s as adjunctive treatment for psychotic symptoms themselves, but also for metabolic comorbidities in schizophrenia. And there are a couple of RCTs that have found that you can prevent weight gain or triglyceride abnormalities in in individuals with schizophrenia treated with antipsychotics by using omega-3 supplements, so that's kind of interesting. In terms of the effect on psychotic symptoms, it's more heterogeneous. So there seems to be more of a signal in early disease that omega-3s can potentially have an effect as opposed to chronic illness that's less clear.
Dr Laura LaChance: [00:30:46] Um, there are no so there's, there's some, you know, people have looked at probiotics, people have looked at different micronutrients like a bunch of the B vitamins, for instance. In terms of whole diet interventions, so I'm involved in a randomised controlled trial of a virtual care intervention to target diet, exercise and smoking in youth with first episode psychosis. So again, the intervention is, is like it's a compound intervention, it's complex, it has, you know, those three elements. It's not just diet, but, you know, it's an intervention where we follow participants over 12 weeks and we help them make changes in their health behaviours and so I have experience with participants from that research study of just like, you know, experiencing huge changes in not necessarily psychotic symptoms, but mood, energy within a diagnosis of schizophrenia after making dietary changes. Concentration is another big one that comes up, motivation, and so you know we can think about also the comorbidity of depression or of even negative symptoms in schizophrenia as targets for dietary interventions aside from the psychotic symptoms themselves.
Gray Meckling: [00:31:59] Yeah, that's all fascinating and I think I'll just point out to our listeners that we'll link to the scoping review that you mentioned, and I did flip through some of it, it was very fascinating. So that's, the paper is titled Diet and Psychosis: a Scoping Review, and you can find that in the show notes beneath the episode if you want to learn more about that. There's a lot of great information there. So I didn't have any other questions. I wanted to see if Sarah and Nima wanted to jump in with anything.
Sarah Hanafi: [00:32:27] Yeah. Um, so I was, you know, I was hoping to maybe tease out a little bit more of your experience in trying to capitalise on this mode of intervention and what might have been maybe some of the challenges you've encountered. I know you've alluded to, to how perhaps the tide is shifting in terms of the interest in the field, but certainly I can imagine that there's still kind of some progress to be made. And the first one that certainly comes to mind is even just obtaining like the necessary workup, is that something that sometimes you face some resistance when you're ordering certain bloodwork or other investigations for your patients or even, you know, consulting, nutrition?
Dr Laura LaChance: [00:33:13] Yeah. I mean consulting nutrition as a psychiatrist is certainly a challenge. Um, but the, I mean, yeah, I really haven't had very much luck with that at all actually in the hospital setting that I work in. So I do feel like I'm kind of on my own a little bit, which is unfortunate. Um, in terms of the workup, I mean, the workup is the dietary history at this point because there's not so much that you can actually order in terms of blood tests. So like I mentioned, ferritin and along with CBC is something that I order for anyone with depression or anyone who has risk factors for decreased intake of iron. Um, and then, you know, if they're anaemic, we can order B12 but, and or folate, but that's like pretty much it, or you can order B12 if there are other risk factors for B12 deficiency. But we're very limited in terms of what actual lab tests that we can do. So the workup at this point is, is the dietary history. Um, and you know, I'd love to see, um, you know, in Ontario for instance, it was really easy to get what's called an Omega-3 index, which is basically a blood test that measures the amount of, so it gives you the percentage of EPA and DHA that's been incorporated into red blood cell membranes and you can use that as an indicator for people, you know, to identify people who would be preferential responders to supplementation with omega-3. You can use that to target the dose because we have, you know, ranges for what the omega-3 index should be between 8 to 12%. But we can't order that here, I haven't been able to find a private lab that can do it and so that would be really that would be really wonderful.
Nima Nahiddi: [00:34:54] For you, what would be some of the questions you would ask your patients in order to get key elements of the dietary history?
Dr Laura LaChance: [00:35:00] Yeah. So it's like really bare bones. So the first thing I do is give people some psychoeducation about the role of nutrition and mental health. So I'll say something like, you know, your brain is an organ just like every other organ and it needs the proper fuels to function and if your brain isn't supplied with the right nutrients, it can't function in the way that it that it needs to. So, for instance, doing things like making neurotransmitters, having your neurones communicate with each other, all of those processes require nutrients to function properly. So then I'll ask people, is it okay if we talk about your diet a little bit in relation to your mental health? Because sometimes people are, you know, they're a bit confused, right? Or they're not used to having mental health professionals ask them about diet.
Nima Nahiddi: [00:35:38] Yeah.
Dr Laura LaChance: [00:35:38] So ask permission, give some psychoeducation and then I'll ask people to start about the number and timing of meals and snacks. So how many meals do you eat a day? How many snacks do eat a day? Do you generally eat food at home or are you picking up food or going to eat at restaurants? So just have like a little bit of a landscape, right? So the person who, you know, doesn't eat anything at all until 5 p.m. and then snacks all night is very different from the person who eats three meals and two snacks a day. So that's the first question. Then I go through, I go for like, biggest bang for your buck. So how many servings of vegetables do you eat in a day? How many servings of fish and seafood do you eat in a week? And how many servings of sugar sweetened beverages do you eat in a day? And like that is, you know, I mean, you can often get find targets for intervention right there. You know, lots of people have many vegetables do you eat? One. How much seafood do you eat? No, none. How many sugar sweetened beverages do you have? Oh, just two, you know, so that's kind of a really easy place to start. And then the next question kind of if I have time and people are actually cooking at home, I'll ask them about what kinds of cooking fats do they use in the house and to try to shift them towards olive, avocado or coconut oil if that's something that's of interest to them. And so that's kind of where my assessment. And then as we've been kind of talking about this, you know, people have like even, you know, the somebody with the most basic food literacy, they usually have some idea of something that they could do better with their diet. So even just from talking about it, I'll ask them, you know, is there is changing your diet something that you feel that you could do? You know, what's your motivation? What's your confidence that you could make a change? And then do you have an idea of something that you could change about your diet? And like that, you know, you don't need a nutrition degree to do any of that.
Sarah Hanafi: [00:37:38] So it sounds like you take almost a bit of a motivational interviewing approach to coax behavioural change.
Dr Laura LaChance: [00:37:47] Certainly, yeah. Yeah. If it's their idea, they're much, much more likely to do it.
Sarah Hanafi: [00:37:53] And you know, you mentioned a little bit how your interest in the social determinants of health is part of what led towards nutritional psychiatry. A lot of the patients that we work with in psychiatry are vulnerable and might have limited access to financial resources or other kind of economic resources. I'm wondering if that's a challenge that you've encountered sometimes for patients who may be interested in adopting diet-based interventions or other kind of physical activity changes, but are limited.
Dr Laura LaChance: [00:38:34] Certainly. So, I mean, one thing is, you know, work with, so collaborate, so, you know, working with our social work colleagues to ask them about resources in the community for nutritious food. There are a lot of different options out there, and we can't possibly know about everything that exists in our environment. So that's one thing is collaborate. Another thought that I have about that is that restaurant food is often much more expensive than food that you prepare at home. So, you know, shifting toward preparing more food at home can often identify a way where you can make an intervention that's cost neutral. Um, I'm currently in the process of evaluating a handout that I created based on the scoping review with one of my colleagues, Dr. Monique Aucoin, about and it's actually Aucoin, not Oakley, I'm not mispronouncing it. And it's a handout that's specifically made for individuals with severe mental illness and there's a section on there about, um, about eating well on a budget. And so certain items like, you know, frozen vegetables or very inexpensive, buying like dried beans and legumes, very inexpensive, um, eggs, another source of complete protein, healthy fats that can be added to many different kinds of meals, many different types of cuisines. So like, obviously there, you know, it's more challenging for sure, but everything else is more challenging also with an individual who is, you know, facing barriers like insecure housing and, you know, substance use and, you know, everything that we see of patients poverty really in general. So, um, I think you just you meet the patient where they're at and you try to make an improvement, you know, in one step. And just because you can't have them, you know, eating a $20 salad from pick a restaurant, um, it doesn't mean that it's not worth trying to make some gradual changes with them.
Sarah Hanafi: [00:40:35] No and I think I think you make a really good point, too, about those opportunities to collaborate and lean on other members within the team or other resources to support our patients and in making these changes within their life.
Nima Nahiddi: [00:40:50] All of, all of this has been really fascinating with the discussion on some of these really basic questions we can ask the patients in order to get really important information about their everyday habits and move forward with these dietary patterns and, you know, really get them interacting with us and becoming better clinicians ourselves. Do you see future directions for nutritional psychiatry? Do you have anything in mind as to what's going to be next steps in the field or what's going to be things to come?
Dr Laura LaChance: [00:41:35] Um, yeah. I mean, so I think this podcast is a really nice next step and examples like it so thank you for giving the topic some attention. Um, you know, I look forward to opportunities for more nutrition education and as part of medical education in general so that we can have nutrition be on our radar as doctors. Um, I think, you know, there's obviously a ton of research to do. We didn't even touch on gut microbiome today, which is a huge, you know, diet is one of the major and most modifiable determinants of the gut microbiome. And I think we're just we're in like we're just in the dark. We don't even understand what a healthy microbiome looks like versus an unhealthy microbiome or what a healthy microbiome is even supposed to produce or how to influence that. So I think that's really going to be a major future direction for the field.
Nima Nahiddi: [00:42:35] So my my knowledge about gut microbiome is quite limited. Do you mind giving us a quick update on like what's when you say that or like what is the current knowledge on the gut microbiome? Because it is something, you know, you read about in newspapers, magazines and I would think it's something that, you know, we would be interested in developing more knowledge about. But do we have current evidence or what's the current knowledge about the gut microbiome?
Dr Laura LaChance: [00:43:06] So, so you know, microbiome as it relates to mental health has a number of important functions. Um, mostly so the microbiome is, is crucial in maintaining that barrier between outside of the body and inside of the body at the level of the gut, right? So we have this gut epithelium or intestinal lining which protects the inside of our body from what's in the lumen of our intestines. And if that barrier is not functioning normally, then, you know, toxins from food, bacteria can translocate, bacterial antigens can translocate across the gut lining and get into our circulation, and there they can cause an immune response. And that, you know, when we talked about inflammation earlier and inflammation being an important mechanism in mental illness, the question of where does this inflammation coming from? Well, a lot of people think that it's coming from the gut for exactly this reason, because the gut lining is not intact. So the microbiome plays a massive role in terms of maintaining that gut barrier integrity. It also produces a number of important molecules like short chain fatty acids, but also neurotransmitters directly, so, you know, of obvious relevance. Um, and it modulates the HPA axis, which is our stress system, which is of also crucial relevance to mental health.
Dr Laura LaChance: [00:44:30] And the gut and the brain are talking to each other. So Sarah mentioned earlier the microbiota-gut-brain axis, and that's a bidirectional means of communication between the gut and the brain, where the vagus nerve is one of the channels of communication but also there are endocrine and cytokine signaling molecules that communicate between gut and brain. So, um, I think like, you know, there's, there's a lot of overlap when you start to dig into these mechanisms but I think what's super important and I think exciting about the gut microbiome is how modifiable it is. And so, you know, you can modify the gut microbiome with, with probiotics, with synbiotics, with postbiotics, with, um, faecal microbial transplant, but also diet is actually coming out as the most potent way of changing your microbiome. So if you change your diet for a couple of days, you can see dramatic shifts in the composition of the gut microbiome. And so I think that's going to, you know, I hope as that field develops, we start to see, um, a lot more attention to, to diet there.
Nima Nahiddi: [00:45:35] It's really fascinating.
Dr Laura LaChance: [00:45:37] I mean, it is and it's just like it's a whole other, you know, like layer of complexity to apply to the physiology that we already understand about our bodies. So it's hard to even wrap your head around it. But we have now we've got at least five randomised controlled trials in depression of probiotic interventions. We've got one in anxiety, we've got two in schizophrenia and like I said, it's early days because I don't think we know what a healthy gut microbiome even looks like, so I don't think we know which kind of probiotic to prescribe. So my response to that clinically right now is we know that you can support a healthy gut microbiome by avoiding things that damage the microbiome, like ultra processed foods and sugar. We can support a healthy microbiome by providing our gut microbiome gut microbiota with lots of healthy food, which is fibre, right, another another word for it.
Nima Nahiddi: [00:46:29] Yeah.
Dr Laura LaChance: [00:46:30] Um, and then we also know that we can consume fermented foods directly so we can eat things like yoghurt, kimchi, sauerkraut, whatever, kombucha, if you will. Um, and, you know, those are all sort of safer things that, you know, are actually probably more cost effective than probiotic supplements anyways.
Nima Nahiddi: [00:46:52] And it's nice that even though, you know, it seems that we're at the tip of the iceberg for, you know, what we know about the microbiome, there's still a lot of things clinically that we can recommend to the patients.
Dr Laura LaChance: [00:47:05] Yeah. And I mean, there's a lot of convergence, right? We've been talking about anti-inflammatory diets. We've been talking about supporting a healthy microbiome and, you know, having lots of fruits and vegetables like, the Mediterranean diet is essentially a template that everything kind of converges in that direction. And I realise that not everybody on the planet is going to consume a mediterranean diet for various reasons. But you know, it's rich in fruits, rich in vegetables like beans, legumes, whole grains, you know, fermented foods, healthy fats, not refined carbohydrates, not sugar. And those are really just like, I think, take home points at this point.
Gray Meckling: [00:47:43] Well, that was great to touch on all those future directions. And I for one, I'm grateful that we've had such an expert on the topic to to chat with, and we can count on you to sort out all of these research questions. The last topic we wanted to touch on was just if you had any tips or advice for for someone who's maybe in medical school or early on in their residency who is interested in nutritional psychiatry, where they can learn more or how they can get involved.
Dr Laura LaChance: [00:48:12] So there is a society that I alluded to that's called the International Society for Nutrition and Psychiatry Researchers, and it's actually probably 50% researchers, 50% clinicians. But they have an absolutely fascinating conference every two years and it just happened in 2019, so it'll be 2021 in Vancouver, actually. Um, and if anyone's interested in learning more about the field, that is where the experts are. It's a group of about, the last conference was about 200 people and it was like, you know, I felt like I was, you know, in Hollywood, like seeing all the stars. And, you know, it was so that's something that I would strongly recommend to anyone who's interested in the field because you'll get the the most kind of cutting edge knowledge. Um, I mean, if anyone, like anyone at McGill who's interested, please reach out to me, I'd love to chat with you and like, you know, we can definitely talk about it. So you're welcome to share my contact info in the show notes also. There's a Food and Mood Centre at Deakin University that was created by Dr. Felice Jacka, who's probably the, um, she's probably the most, I guess, famous researcher in the field. She's the person who actually started the society and she's like kind of the mother of modern nutritional psychiatry, I guess. Um, and so it's called the Food and Mood Centre at Deakin University in Australia and they have a course on food and mood that's free on, through FutureLearn and so if you're wanting to learn more as a clinician or just as a person who is interested in making healthy changes to your life, that's a good place to get really high-quality information. Um, and you know what I would say if anyone's interested, I mean, read broadly and start talking to your patients about their diets. I don't, you know, I don't think we need to wait for that.
Gray Meckling: [00:50:06] Yeah, that sounds like great advice and we'll definitely link to some of those resources in the show notes so thank you for sharing all of that with us. I think I'll hand things off to Sarah now.
Sarah Hanafi: [00:50:17] Yeah. Thank you so much, Dr. LaChance, for joining us for this episode. You know, I think I can speak for our listeners in saying that maybe the takeaway, the takeaway from all of this is that nutritional psychiatry is something that's actually quite accessible. It's something that, you know, in speaking with our patients, we can quickly ascertain opportunities for intervention by not only trying to to work with our patients and meet them where they're at, but also work with our colleagues and finding and facilitating access to to resources. So I think that that gives me a lot of hope as a trainee that I feel like a little better equipped to address some of this when I'm caring for my patients. So we really thank you for your time and for our listeners, keep an eye out for the show notes. We'll make a point of linking many of the the useful resources that Dr. LaChance mentioned today. Thank you.
Dr Laura LaChance: [00:51:16] Thank you.
Alex Raben: [00:51:26] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sara Hanafi, Dr. Nima Nahiddi and Gray Meckling. The audio editing was done by Dr. Alex Raben. Our theme song is Working Solutions by Olive Musique. A very special thanks to our incredible guest, Dr. Laura LaChance, for serving as our expert for this episode. You can contact us at Psychedpodcast@gmail.com or visit us at Psychedpodcast.org. As always, thank you for listening.