Psychiatry & Psychotherapy Podcast - Best Diet For Mood Update 2023

Episode Date: July 14, 2023

In today's episode of the podcast, we will explore the significant connections between our dietary choices and our mental well-being. We will discuss practical steps to incorporate diet as part of mental health treatment and maintenance. This episode is the perfect starting point to discover how nutrition can play a role in supporting mental wellness, whether it is new information or an enhancement of current approaches. By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

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research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with soon-to-be Dr. Austin Coleman. He is a fourth-year medical student at Western University. And we will be talking today about the best diet for your mood. Update, 2023, we have looked at the most recent studies to create this episode. We have tried to look for the biggest and the best studies possible. And, yeah, Austin, thanks for coming on.

Yeah, thanks for having me, Dr. Peter. really diet is a big passion of mine and so I'm really excited to be on to talk about how it can you know improve your mental health and more ways than just your physical health. Yeah it's it's one of those things that I would say is underappreciated in residency training I don't remember having one study presented to me on diet in residency. So it's underappreciated. it's difficult because it's a behavior change. So it's like, okay, we're going to go through studies,

but it's like actually changing a patient's behavior who's really depressed or anxious is really hard. Right. And it can carry a lot of shame. Food is culture. You know, how your family eats, how your friends eat is culture. And so it's like it's beyond some aspects of normal, change because you you know if you like restrict something it's like very difficult especially if

it's like what everyone else is doing so we'll talk about these things and more we will we will be emphasizing the power and um i would say the magnitude of the change that's possible so we will be talking about effect size which is like how many standard deviations one group moves from another. Right. Okay. So let's start with a notable study in 2022 by Lang et al. Tell me about this study. Yeah. So when we were first kind of looking into this, I really wanted to see, you know, aside from what can we add or change about your diet, what are the things about our diet that is really hampering our mental health? Like what's, what's the negative factors here? So in this Lane at all study, they had a comprehensive analysis first on depression.

They looked at depression and anxiety. But first on depression, they looked at eight studies with a total of 102,000 participants. These were in Spain and in France. So among these studies, they had two of them that were prospective. And in those prospective studies, they found that a higher consumption of ultra-processed foods had an increased risk of developing depression

or experiencing depressive symptoms with a hazard ratio of 1.22. And those prospective studies, that sample size was 40,000, 41,000. Yeah, so diet studies, you know, you can imagine that, oh, it's like studies of 50 people. It's like wrong. These are huge studies, huge. And a hazard ratio of 1.22 is kind of saying, like, okay, if you ate ultra-processed food during this study, you had the risk of like a 22% higher chance of developing a depressive episode.

So from a hazard ratio, you don't know it's causality. You don't know like this is causing. Like is someone who's more depressed, more likely to eat junk food? Or someone who's going to be depressed in the future, like early symptoms of depression might be not taking care of yourself. So that would be like one thing this study doesn't look at.

But we'll look at more studies. So let's keep going. Right. So still on depression. They had six more studies. These weren't prospective. These were cross-sectional and design with 15,000 participants. And they also showed a higher likelihood of depressive symptoms with a greater consumption of ultra-processed foods. These being an odds ratio reporting of 1.44. So again, less direct than a hazard ratio. but an increased odds of depressive symptoms. So this is looking at a snapshot of time. It's looking at a huge amount of people and looking at if they're depressed

and what is the odds that they're also going to be eating a bunch of highly processed foods. And so if you're listening to this, you're like, okay, I want to avoid highly processed foods. We are going to get there. But just think, someone who's depressed, 44% increased chance that they're eating a bunch of highly processed foods. So the two are like linked, right?

There's an increased odds. Okay. Okay. What about anxiety? Yeah. So then anxiety, we get into that. We have six more cross-sectional studies about anxiety. This had 200,000 participants in these, like, total in this studies.

and their association between ultra-processed foods and anxiety symptoms reported an odds ratio of 1.48. So pretty similar to the odds ratio that we just found for depressive symptoms. Yeah. So a snapshot of time, right, cross-sectional study, 1.48 higher odds, if they were depressed, eating ultra-processed foods. Okay, keep going. So then they were like, well, what if we put it together? So they did five cross-sectional studies again. snapshot in time with 185,000 participants and they said, hey, what's the link between higher

consumption of ultra-processed foods and experiencing depressive plus anxiety symptoms, the both of them? And the odds ratio for that one was 1.53. Yeah. And these confidence intervals are pretty tight. It's like the odds ratio of 1.43 to 1.63. So the confidence interval is saying like, okay, we can, within a 95% chance, this is where the odds ratio would fall. We don't know exactly where,

but this is a round where. So it's pretty high. It doesn't cross one, which would mean that we don't know if it's happened by chance. So the P value is super low. So this is an actual verifiable link, depression, anxiety, eating ultra's processed foods.

Now, I think from clinical experience, I would say people who are depressed, anxious, don't eat as healthy. I see it as bidirectional personally, and we'll get into how it might be beyond, or how changing your diet changes your mood, right? Because if it was purely just, no, the people who are eating ultra-processed foods are doing that because they're depressed. And it doesn't change their depression, it doesn't change their anxiety. it's just because they're more anxious and depressed that they're eating that. It's not worse seeing their depression, right?

So someone could make that argument. If you made that argument, then if you changed someone's diet, it wouldn't really change their mood more than an act of control. And we will show... If we just had these studies, that's all we would know is that there's a link. Yeah. Yeah. There's a link. So we don't have a causative relationship. yet, but we're going to get there. Okay. Before we get there, though, before we get there,

I kind of wanted to touch on, like we're saying, hey, you know, in huge studies of many, many people, we're finding that there's increased odds, increased hazard ratio risk in one study, in two studies of increased depressive and anxiety symptoms, but like what are ultra-processed food so we can try to, like, stay away from that. The authors, they use the Nova food classification system, and I just wanted to quote them here, so I didn't get it wrong. They say that NOVA distinguishes ultra-processed foods as industrial formulations generated through compounds extracted, derived, or synthesized from food or food substrates. Ultra-processed food items are characterized as containing five or more ingredients, which typically include artificial food additives rarely or never used

in home kitchens, such as preservatives, colors, texturizing agents, olfactory, and, and taste enhancers. Yeah, so this food, the food lists that are ultra-processed are low-priced, convenient, have a very long shelf life and are usually highly palatable, right? They're like tasty. Like those like cheese puffs that are just like delicious, right? They're just like... A lot of calories cram-packed and like a little thing that tastes really well and it will

last 20 years. Yeah. So I want to pause, I want to pause here and talk a little bit about like what are, what are those added things that are not on your shelf, right? On your shelf, you do not have sodium nitrate, sodium benzate, sulfites, you know, which are preservatives. You don't have sweeteners like you probably don't have a jar of high fructose corn syrup, right? Esparamine, sucralose, saccharine. You don't have those fake sugars like in your cabinet,

probably. You don't have artificial colors. Like you don't have a jar in your pantry of yellow, five, blue blood. Actually,

I just ran out of red dye number 40. I need to, thanks for reminding I put them on the grocery list. Yeah, put that on your grocery list. I just can't wait

to get some more red 40. You don't have artificial flavorings like MSG or artificial vanilla Maybe you do, but most of us don't. You don't have texturants like xanthine gum, grouar gum. You know, you don't have these emulsifiers like soy, less than, you know, stuff like that, right?

Yeah. Great. You know, these are things that mix together oil and water. I think Dijon mustard is a really nice one, actually. I don't know. Hopefully that is... Oh, wow, I do have that. I've got Dijon mustard. No, it's a nice one as in like it's a natural emulsifier.

Oh, really? Yeah, okay. I thought you were saying that these things were in it. Yeah, no, no. It's what I used to emulsify my... Someone's going to say, that is a... Maybe the unhealthy version of Dijon that you use is a... But the one that I use, it's super healthy, right?

Okay, I see. Well, that's the thing. It's like a lot of these things, you can get the unhealthy version, you know, like ketchup, for example. You can get a ketchup with like tons of ingredients or you can get something that's more simple, you know. Okay, there's more. There's more. There's things that make things more acidic or less acidic that they add, like citric acid. There's hydrogenated oils that improve shelf life, improve, maybe create a specific texture, peanut butter you really got to look out for that peanut butter

you know hummus is where I didn't know about hummus the most sad is when I find that like a really good thing of hummus has like tons of these different things and I'm like why can't I just get chickpeas tiffany and olive oil and some spices like that's what I wanted my hummus

yeah so hydrogenated oils like trans fats they don't even allow trans fats in Europe anymore it's so clear that that's so toxic stabilizers are like pectin and agar agar you know and then so pressure that's what you use for like plating bacteria is auger it's it's like so this is what we're talking about when you're thinking about ultra processed foods you just look at your ingredients thing and if you don't know what like half of those are it's probably an ultra processed food I'm sorry that's what the study says.

Don't hate me, hate the authors of this. I'm just giving you the information, right? So what types of food? What types of food are these? These are like things that are in cans, maybe frozen foods, packaged cakes and cookies. If you have a cookie that can sit on your shelf

for years without degrading, it's like, you know, it's like somehow they can sell us a cookie that can literally sit for years without going bad, right? I'm pretty sure they did that with like a McDonald's burger at one point. I think there was a big thing about it. They like left it out for years and years. And it just like looked exactly the same. Yeah, it looked fine. Okay.

Yeah, so then I would say a lot of candy and frozen desserts. look at the ingredients list, beverages, a lot of beverages have lots of additives, processed meats, like hot dog, sausages, you know, stuff that it's like, that doesn't look like the actual meat, right? And then convenience foods, you know, where it's like this is pre-made in a package ready for you to eat it. Okay. So that gives you an idea what an ultra-processed food looks like. And then, yeah, what kind of vague, you know, it can be a vague description. Hopefully that wasn't so vague. But what does it say about the nutritional value of these foods? Yeah, it's, so they talk about that in their study. They say that Nova, the classification system in

itself, it ignores nutritional components, but there's an association that a lot of these ultra-processed foods are usually sources of high energy. They lack various fibers. Most of the things that you would find in a very plant-based or like a whole-food diet, you're not going to find in these foods. They've either been stripped of those or just don't naturally have them occurring. Yeah, so you're not going to have fiber omega-3s. If you have vitamins, sometimes they add them secondarily, which is, you know, like, would you rather have a vitamin naturally occurring or, like, added, right? Yeah, so there's some different things.

I've even seen, as they change from, like, ocean salmon to farm salmon, the omega-3 content shifts. Now, I think both are pretty good for you, probably. I don't know, I don't want to be, like, nitpicky. I think some people can get obsessive about, like, a lot of things. but for me, salmon is salmon. It's probably good for you. It's that algae.

They're not getting it in the farm. They're not getting the algae and they're not getting the swimming environment. And so if you look at the color of farmed salmon, it usually is a lot more white and pink because it's a lot more fatty. And the fat that it has is lower in omega-3s. So I'm just saying, like,

as we move away from naturally occurring fruits, vegetables, animals, it changes it. Our corn-fed cattle is the same, lower in omega-3s, not by a huge amount. There's not much omega-3s and beef, from what I can tell. Compared to like salmon, there's a ton of omega-3s and salmon. Oh, sardines? Sardines, yeah.

Yeah, but it's just a general thought that as we move away from like the natural occurring foods, right, to more industrialized, packed together. And you see like companies are trying to sort of, we added some DHA to this milk. It's like, it's good that you're paying attention that we think that's important.

Let's keep going. Oh, it changes your gut microbiome. That was another thing we found. Right. And I think that's in one of the studies near the, we'll get there. Near the end of this list here, yeah. We'll come back to that.

But just think about like, okay, so there's, if you were to drink, artificial things that don't exist in nature. It messes with your gut biome as well because those things are like maybe those bacteria are not used to that kind of like fake sugar and stuff like that. And you get some fake bacteria on board. Fake bacteria. They'll be used to that.

Yeah, the fake bacteria eat fake sugar. Yeah. Oh, gosh. Okay. So enter our next study. Heliolius, healthy life in an urban setting study. Tell us about this one. So after the whole, like, oh man, you know, there's ultra-processed foods, we should stay away from that. I kind of wanted to look into macronutrients and be like, you know, what specifically about a lot of these foods is causing

the depressive and anxiety symptoms? Well, I mean, I can't prove the causation, but is more highly associated, I should say, with the depressant anxiety symptoms. And so I came across the heliase study. by Vermeulen at all. And this took a subsample of participants from their original Helia study, which was a large prospective cohort done in Amsterdam with around 5,000 people. And they really were just looking at social determinants of disease burden. So they took this subset and they assessed them for depressive symptoms using the PHQ9, based on their belonging to one of three different dietary patterns.

They either had people that were in the high sugar group. This was characterized by a high consumption of sugary beverages, fruit juices, added sugars, the high-saturated fat group that had a high-consumption of butter, high-fat dairy, low intake of nuts, seeds and vegetables, or the high-sugar and high-saturated fat group, which ate a lot of sweets, a lot of red meats, high-fat dairy products, creams, and fried foods. So they looked at these guys, and they all had pretty similar BMI's, and they controlled for other characteristics that may have been confounding variables. And they took the lowest quartile of those consuming a high sugar and a high saturated fat dietary pattern and compared them to the highest

quartile. So people eating the least of these things to people eating the most of these things. And they found that specifically the high sugar, high saturated fat combined dietary pattern was associated with more depressive symptoms, an odds ratio of 2.36. Yeah, interestingly, the beta was the diet, let me say the full sentence here. The dietary pattern associated with more depressive symptoms when they looked at quartile 1 versus quartile 4. The beta was 0.18. This is a regression co-ofeiting. in a linear regression model.

It indicates how much the dependent variable, in this case, depressive symptoms, is expected to change the corresponding independent variable. Here, the high sugar, high saturated fat, dietary pattern. So, you know, how much does the change, how much it changes in one unit holding all the other independent variables constant? So in the context of this study, the beta equals,

to 0.18 means that for each unit increase of the high sugar, high saturated fat dietary pattern, the depressive symptoms score, as assessed by the pHQ 9, is expected to increase by 0.18 units on average. So it's not a huge increase, but if you look at more of a population type of study and more of the people who are vulnerable, it's going to make it, it makes an impact. Right. And I thought really interesting was when they looked at all three of the dietary patterns. It was significant in the high sugar, high saturated fat,

but not significant increase in either the high sugar or high saturated fat. I isolate it. Yeah. Yep. Okay. Let's keep going. So if that wasn't clear to you, let's just say the takeaway is a part of ultra-processed food is high sugar, high-fat.

Because those are things that are often in the highly processed foods. And so in a super-highly processed food diet, there's higher sugar and higher fat both together. And when those two are both there, it's going to increase your risk of depressive symptoms. Yeah, I mean, sweet and salty together. It's a killer. Sweet, sweet and like savory, right? Right, yeah. Yeah, I was disappointed the other day when I found out my favorite beef jerky had like tons of sugar added. Yeah, that's so surprising because I feel like when you take a chomp out of a piece of beef jerky, you don't expect a lot of sugar in there.

It's like, it like sneaks up on you. You know? Okay, let's keep you on. So let's talk about one of my favorite diet studies, the Smile trial by Jacka at all in 2017. Yeah. So we kind of wanted to, after that, see, you know, what do we have left if we say, oh, let's not eat highly processed foods with high sugar and high fat. Is there anything left to eat? And so we kind of looked at these studies to see, you know, what is left and what can improve our mental health rather than deteriorate? rate it. And one of the best ones is, of course, like you said, the Smiles trial by Jacka et al. This was done in 2017. And this was a major landmark study. You've already

covered this study in your previous podcasts, I think maybe once or twice. Like, it really just came out of the gates. And so they have a randomized controlled trial. They really just wanted to look at the impact of food on depression, specifically on the Mediterranean diet. So they took a 12-week study with 67 participants. They split them into two groups. They have dietary intervention, and they have a control group. The dietary intervention group, they got nutritional counseling promoting the consumption of essentially a Mediterranean diet.

We're talking whole grains, vegetables, fruits, legumes, low-fat dairy foods, raw and salted nuts, fish, some lean red meats, some chicken, some eggs, and olive oil. and they were told to reduce intake of foods that we just previously mentioned, like sweets, refined cereals, fried foods, fast foods, processed meats, and sugary drinks. So that's the intervention group. The active control group, they got social support sessions that was basically a befriending activity, discussions with, you know, people with shared interests, they played games, had book clubs, whatnot.

Everybody, regardless of their group, were recruiting. based on their initial poor dietary habits. So they used a dietary screening tool, and they had to have gotten a score of 75 or less in their specific screening tool, indicating that they already had a poor diet at the onset of this study. Very important point. Very important. These were people that had a poor diet coming into this study. Like, that's how they selected them. And I think that's part of the success, right?

is like change a group of people with poor diet, see how much it changes their mood. Okay, keep going. Exactly. So what were their primary endpoints in this? They wanted to look at depressive symptoms using the Montgomery-Asberg Depression rating scale. So this has 10 items. It's a 6-point scale, maximum score of 60 with higher, meaning more depressive symptoms. Remission had a score of below 10.

and so what they found really quick write out the get-go is the dietary intervention group actually had a 32.3% remission of depression, so below 10 on the Montgomery Asperg depression scale, while only 8% in the control group actually experienced the same outcome. That's significant. That's a significant chunk of people who went all the way into remission. and so if you look at this dietary intervention group you know it's like number needed to treat let's say it's 20% number needed to treat is five to get one into remission right

for those of you who are thinking like that doesn't sound like a lot it's like everyone was shift it's like overall the effect size was important so let's let's keep going with what other things they found right so they when they actually looked at these scores I'm just going to say the madras. The madris score was the average reduction, I should say, in the madras score, was 7.1 points greater in the diet group compared to the control group. So this is an effect size of negative 1.16.

Which is huge. Like, when you get an effect size of something greater than one, this is very significant. Like, just to give you an idea, an effect size of somewhere, on one might be 20 to 30 sessions of psychotherapy. And effect size of one, usually you don't see that with antidepressants. Usually you see it maybe like a 0.6 or a 0.7 if you're talking about the most severe levels of depression, like Simbalta. I've seen that. other SSRIs,

SNRIs, they don't work as well with mild, right? So, but at more severe levels of depression, you get a bigger shift. So yeah, this is a significant shift, significant effect size.

Of course, you can't compare apples to oranges, like I can't compare this to antidepressants, because with antidepressants, the placebo works really well too. And the placebo works well, I would say maybe with,

with the exception, if it's like treatment resistance, depression, right? From the star D data, we have like treatment resistant depression does not change much at all. Right. Maybe 6% will get better, you know, if you're treating treatment resistant depression. So placebo doesn't work. Most medications don't work for treatment resistant depression. Unfortunately, that's what we see a lot in our practice. So it's like we have to think outside the box. We have to think about other things like could diet be part of the big picture, right? That could help someone. Okay. So, right, especially like if you've, if you've

already tried one antidepressant and like, you know, you mentioned the star D, like your chances after, after that one and especially two just get incrementally, like massively lower. Massively lower. Yeah. And so we have, we have to consider other things other than purely medication. And so if their diet is horrible, I put that on my list. And it's something that I'm going to be continuing to work on every time they see me. It's like not the cure-all. I think there are some people who think like diet is the cure to everything. But it's like, okay, it's not like 100% went into remission. Yeah. Yeah, I think what we're going to see is that it has like a really great role in adjuvant therapy. Like you're like do this at the same time. It's part of the

picture as you get healthier, especially people are higher risk, like my higher risk, depressive genetic, anxious patients. I'm like, how can we optimize different domains of your life when you're doing well so that it lowers your risk of future episodes, lowers that hazard ratio, right? Right. Okay, so what actually changed? Whenever you look at a diet study, it's really important to look at what actually changed

because if you don't read that, it's usually in the results portion. So in the methods portion, they'll say like how they measure the change and the results portion, they'll say like, okay, the treatment arm actually made these changes to their diet. And so as someone who's like you, my listener,

is going to start reading, is going to start reading these studies, right? Just like you would, any other treatment, you want to get knowledgeable, you want to improve your knowledge. So you want to start reading these studies, you have to look at actually what changed. So tell me what actually changed. Yeah, I think what actually changed really goes in line with all of the things we just previously mentioned, because I'll just go ahead and say it. They had notable increase in a lot of these different Mediterranean foods, and so they have

whole grains, they ate 1.2 more servings a day, fruit, they ate 0.46 more servings a day. They had more dairy, more olive oil, more servings of chickpeas. And they all hover around like half to one and a half servings a day or per week depending. But really the biggest thing is that they decreased unhealthy food consumption by 21.76 servings a week. Right. So that, that to me was the highly processed food. that they eliminated. You know, a little bit of increased, like half a fruit more per day. They ate a little bit more whole grains every day, like one serving,

drank, maybe half a cup more of milk or some sort of dairy thing. These are small changes, but then the big decrease is basically three unhealthy foods that they were eating per day that they reduced, which is big. Okay. It's much bigger of a change than any of the other what they added. Yep. Okay, someone is going to say, yeah, this is great for you guys. You guys are like in a cloud, it's expensive to eat healthy. What would you say to that person? I would say that I have discussions about this all the time because I personally ate a whole food plant based. I'll stick with what the study has to say. Smiles had something to say about that.

They knew somebody would ask. And so they looked at it. They said, hey, in the beginning, how much are you guys spending on food? And this was an Australian study, so it's on Australian dollars. In the beginning, participants spent an average of $138 per week on food and beverages. And when they followed the recommended diet in the intervention group, they had an average cost of $112 Australian dollars per week per person, making it $20,000. Australian dollars cheaper per week. And when I wrote this, that was $18 of 18 U.S.

dollars at that time. So they're saving 18 more U.S. dollars per week when they changed from whatever they were eating before to the intervention study diet. And then I made the key point. Okay. So now this is going to face it for you guys. Like prepare your minds to be blown. Okay. Compounding interest. If you were to take $100 a month and put that $100, a month into like an index fund, like let's say an S&P 500, make it simple. And you get a rate of return, which is around what we've seen historically for the SP 500. In 50 years of investing $100 a month, you will have close to a million dollars. So not only will you save money by eating healthy, but you will become a millionaire.

You heard it here first. here first, yeah. Oh, man. Compounding interest is great, guys. I don't talk enough about this, but if you haven't thought through the long-term benefits of capitalizing on compound interest, you should think about that, at least for four hours a year when you plan your investments. Okay, let's keep going. Yeah, so after that, you know, we have this Miles trial. That was in 2017. And, And we wanted to see what's recent, like what's new after the Smiles trial that can either say that their study was valid in what they found or they can invalidate the Smiles trial.

And the first one I wanted to highlight on was the Healthy Med study. This is in 2019 and by Parletta at all. They also set out essentially like the Smiles trial to do a randomized control trial on the Mediterranean-style diet. with fish oil supplementation on improving mental health and individuals with depression. So these guys took 152 participants. They were aged 18 to 65. They had to have either diagnosed depression or self-reported depression symptoms within the last two months. And the inclusion criteria for that was moderate to extremely severe depression on the depression anxiety stress

scale 21. And so I've got a little list up here. That means on this expanded scale of 42 points, they had to be above 14. And they had to be 14 to 27 is the moderate to severe category. And that's where they're starting. So they took all these people. They had to have that amount of depression starting. And they split them into the med diet group and the social group, 75 individuals in the Med Diet 77 in the social group. The Med Diet, they received fish oil capsules with 450 milligrams of DHA and 100 milligrams of EPA. And they also got nutrition education and cooking workshops every two weeks for a duration of three months. These cooking workshops looked at Mediterranean-style foods. And they also received the recipes and ingredients for the foods that they learned how to cook

as well with additional online and printer resources to tell them how to do it when they go home. The social group got social sessions every two weeks for the duration of the three months, which mirrored the amount of time that the med diet group got to meet up. And in these sessions, a lot like the Miles trial, they played games, they shared meals, they made friends. And that has value. Friendship has value. So it's a good control. It's an active control. It's not like a weightless control. You know, it's not like they're just waiting to enter the study or something. Right. So after three months, what happened? This was three months or 12 weeks, exactly like the Smiles trial above it. And their primary outcome was the Das 21, the same thing they used for the inclusion criteria. So they found that both groups had improvements, but the Med Diet group had a greater reduction in depression. And these changes is the mean Das 21 score for the Med Diet group was 23 at base. and then 12.63 at three months, whereas the social group was 21.79 at baseline and 15.94 at three months. So in total, that means that the DAS scores for the MedDiG group, the difference was 4.52 between them.

Right. Okay. So the DAS group, the diet group reduced 10.37. The control group had a reduction in 5.85. five. So, you know, some people got better spontaneously. Some people got better because of the increased social interactions. But in the DAS group, changing their diet, learning about healthy diet, learning how to cook healthy foods, that made the biggest reduction. So you had this 4.5 difference between the two groups. Yeah, and I thought that was pretty cool because when you look at the actual scale, like the moderate and the severe, you know, categories, moderate is between 14 and 20, and severe is between 21, 27. So that's just the six-point difference between, like, between these different categories. So a difference of 4.52 is almost getting you to a completely

different category of depression based on how they scale it. Okay. Yeah. And so that could shift your category from severe to moderate. Or, moderate to mild. So I think I, the reason why we like to think about like the ranges of the scores and how it's scored and how many points the scores are

is so that we can make these clinical, you know, like is this clinically a large enough movement in this scale for this to be meaningful? You know, like if it's a meaningful movement or not, If it was a difference of one point, I would say it's probably not meaningful. Don't waste your time.

But I feel like this is a meaningful drop. Especially like a lot of the times it is. Like we treat with medications and we don't get a full response. We don't get the full remission. And so we want to get that full response. Or we treat with therapy and it's helping, but we want to get a little bit more. of a response or therapy plus medications and we want more of a response it's like add some diet changes add some exercise make sure we treat that obstructive sleep apnea right you know that kind of

stuff and i mean if you're stalled and you just try something and it changes by four point five points i mean that's something yeah that could be the difference of i feel like i just want to line the best all day to, okay, I'm finally willing to try some exercise. So sometimes, like, for those of us who are treating patients, it's like small incremental improvements can increase hope that we're moving in the right direction. It can lead to more momentum to do other things for themselves, like that are maybe even more difficult than changing their diet. like really doing deeper work in therapy or starting to exercise or, you know.

Yeah, I mean, these points could get you over the hump. Yep. Okay, so let's keep going. Yeah. So we know they had a difference of 4.5 points, and we just talked about that. I wanted to highlight that these changes were sustained at the six-month evaluation mark. So they did this study for three months, and they looked at them again and said, six months, and they sustained the changes. So it made long-term changes. Well, I should say long-term,

but for three months at least. And we wanted to look at, again, with these guys, what did they actually change? And so the Med Diet group, they liked the Smiles trial. They consumed significantly higher amounts of vegetables, fruit, nuts, legumes, whole grains, and consumed fewer unhealthy foods like burgers, chips, pizza, and also less red meat and less chicken. Okay. Great. All right. Let's jump into another study, a 2019 study conducted by Francis at all.

They looked at a younger population, 17 through 35, that were diagnosed with depression. And so tell us about this one. This is my favorite trial we're going to talk about today. And I'll get to Y later. But like you said, it's younger adults diagnosed with depression. They also used the depression and anxiety stress scale, but it's like a more minimal scale. It's on 21 points, so they basically just took the depression and anxiety portion out of it. And so in this one, they had to be diagnosed with depression or have a score of greater than or equal to 7 using the scale.

And so that again puts them into the moderate to severe category using these new scales. This study had 38 participants in each group split between the diet group and the control group. The diet change group, a difference in this one, whereas in other studies, we had cooking classes, we had people actually there showing you, here's how you do this, and later on when you're at home, you're going to do it exactly like we do it here. We're going to meet with you a bunch of times, and we're going to show you how to do this a lot of times in these three months. These guys only received online video instructions. And the video instructions, they said, hey, increase the consumption of foods aligned with the Mediterranean diet, like veggies, you know, fruits, whole grains, legumes, all these things that we've talked about, and decrease the intake of your poor quality foods, like refined carbs, sugar, fatty processed meats, and soft drinks.

So they were given the online instructions, they were given meal plan samples, and then a small hamper of food with a $60 food reimbursement. But they didn't receive anything else. No dietitian telling them how to do things, no cooking classes. They got a five-minute phone call on day seven and day 14 just to ask, hey, how are you doing? Are there any problems? The control group, they got no specific instructions, no befriending action. protocol and they just said, hey, please come back in three weeks. So it was a wait list.

Or like essentially like a non-active control. So and again, this study is a lot shorter than the previous two. The previous two were 12 weeks in duration and this one was simply three weeks and the diet group got a lot less instruction. So what changed and what happened? They use the different primary outcome measures for this one. The Center for Epidemiological Studies, Depression Scale, C-E-S-D-R, or revised C-E-S-D-R. So just to kind of give us a picture for this scale, a range of no, the diet change group, they showed improvement on this scale, transitioning from the elevated range to the range of no clinical significance, so scores under 16 for this scale.

So on day 21, the diet change group exhibited significantly lower scores compared to the control group when controlling for the baseline scores. They had an effect size of 0.65. So the actual numbers, the diet change group went from 20.56 to 14.62 on day 21, a change of almost 6. Whereas the habitual diet group went from 20.28 to 20.81, a different, so they actually, they actually, they actually, went up in these three weeks. And so the difference between them was 6.47 points. Yeah. So it's impressive.

The effect size of 0.65, it sounds more impressive than a lot of our antidepressants. But the control was not a placebo. The control was a wait list. And so in psychiatry, you know, we meet with patients, we talk with them, we do history. There's a lot more that goes on than just giving medication. And so that's why placebos are so powerful in and of themselves,

like in a lot of studies we look at placebos. I would say except for treatment-resistant depression, placebo doesn't do as much. Okay, so we can't compare the effect size of antidepressant trials with the effect size of diet. But what we can say is that this is an impressive effect size. It actually did something. It actually did something.

And we should pay attention to it. So keep going. Yeah. So I wanted to talk about another outcome measure, which was the DAS 21. This is what we've seen in previous studies, and they also used it for their inclusion criteria. So they found similar effects. Their diet change group on the Das 21 went from around 7 points on onset to around 4 on day 21,

whereas the control group went from 7 points to around 6.5 on day 21. So the diet change group had a greater reduction of 2.37 points on the Das 21 in comparison to the control group, which had an effect size of 0.75. And so when you take this 2.37 reduction in points and you look at the actual scale, the moderate depression category is from 7 to 10, and the mild is from 5 to 6, and the normal is from 0 to 4. So if we take 2.37 points, that could really change us from one category to another. So it could move you from mild to normal or moderate to mild, which may be felt clinically. as like, okay, this is better. This is a lot better. Good. Okay, yeah. What about, do you want to tell me about the types of foods that changed? Yeah. So again, with this study, like previous studies,

the diet change group had a significant increase in the recommended foods as they recommended above the Mediterranean-style foods. And they also significantly reduced consumption of foods high in saturated fat and refined sugar. Okay, great. So this was your favorite study. This is my favorite study because they did it in 21 days. That seemed manageable to you. Oh, also because like enough, it's like you could say to a patient, if you make these changes in 21 days from now, you will feel different.

you may go from a severe to a moderate depression or moderate to a mild depression. Would that be a fair statement to someone? I think that would be an almost fair statement to someone because you don't exactly know how much they're going to change their diet. Like if they're going to change their diet in the scale that the people in this study did. Right. So you have to say to someone, like, look, you have to say to someone, like, look, you have to, really change your diet actually. Like, yeah, if you eliminate all processed foods, you may make a big enough change. Yeah. Yeah. I just, I think it was really cool because I feel like it gives,

I feel like 21 days, it gives hope if you're trying to sell somebody on this. You know, like this isn't like a three month, like we need to change your diet for this long. It's like, hey, you know, like, take three weeks, try to change some aspects of your diet and let's see if you feel better. Excellent. Yeah. Really good. Especially because when you talk about starting a new like an SSRI or something too, you sell it on like, hey, this might not have full effect for four to six weeks. This is even sooner than that.

Yeah, absolutely. So where do you want to go from here? Where I want to go from here is the, I had just one more that came after the Smiles trial. And this one, one more study. This is the most recent. This was done in 2022 by Bays et al, and it's titled the Amend Study. So this was much the same as our previous studies. Look at the Mediterranean diet on the treatment of depression,

but they specifically looked at young males. So this one had 72 only males, aged 18 to 25. They had a previous diagnosis of depression. They scored in the moderate to severe range on the Beck Depression inventory 2, and they were found to have a poor diet based on the diet. the Commonwealth Scientific and Industrial Research Organization Diet Survey. So a lot of the same. Except for we just have males now.

We've got a big group of males. They have a poor diet. They either been diagnosed with depression or they have moderate to severe based on this scale. They take them and they split them, much like we did before. And they put them into two categories, either the diet group or the control group. and I wanted to say in particular about this study, I thought it was interesting that they gathered a little bit more data on which participants were seeking what treatment already. And out of the total participants, 45% were already seeing a psychologist, and 35% were already

taking medication for their depression. So these guys were actively doing something. Among those receiving the treatment, the average length of treatment was one year for medications and eight months for psychotherapy. So for the people seeing a psychotherapist, they had already been seeing him for eight months on average. And for the people taking something for their depression, they had already been taking it for a year on average, but they were still in the moderate to severe category. So we're looking at some potential patients who are, I'm not going to say treatment resistant, but what they're doing isn't quite doing it for

them. So they took these participants and the diet group had an hour-long appointment with a clinical nutritionists, several of them. During these sessions, they had motivational interviewing techniques, they had personalized dietary advice, and they set goals with their participants to adhere to the Mediterranean diet. They told them what to eat, and essentially that was that. They had similar appointments at six weeks and 12 weeks, and they were also given a food hamper with $50 worth of Mediterranean foods, like we saw on the previous study. Participants in the control group, This was an active control group. They had befriending sessions of the same duration.

So at onset, six weeks and 12 weeks like the diet group got with their nutritionist appointments. Also, I liken the study. They also gave the control group a $50 gift card because they gave the diet group $50 in food. And so I thought that was a nice way to control because the other studies hadn't done that. So what was their primary outcome? It was the Beck Depression Inventory 2, which they had to have a moderate to severe range of depression at onset. So that is a higher than a 21 point score on this scale of 40 points. At the end, they looked at the diet group and the befriending group, which had similar scores at baseline.

And what they found is by week 12, both groups experienced a decrease in these scores. but the diet group showed a mean change of 20.6 points, while the befriending group had a mean change of 6.2. So the difference at 12 weeks between those was 14.4 points. Wow. Okay. Which is a lot of points. Yeah. Wow. That really jumps out of you. It's like, wow, that was a big change that made here. Every participant in this diet group had improvement of their symptoms.

and 12 of them reported, so 12 of them being 36% reported scores in the lower minimal depression range. So I just, I really liked looking at the study because at the get-go it was like, hey, we have 45% of everybody in here who has moderate to severe depression, already seeing a psychologist for eight months on average, and 35% of these people are already taking medication for a year on average. and then 36% of the people in the diet group went all the way down to a lower minimal depression range. So, you know, could you imagine if you're one of those people who for a year you're taking a medication or for eight months you're seeing a psychologist, you're still moderate to severely depressed, and then you do this for the 12 weeks and now you're down in the low and minimal range. Yeah, I can see why you get excited about it. It's crazy. It's exciting. It's really exciting. Yeah. I wish everyone got excited about this. Were you as excited before I had you

do this project? No, because I hadn't read this study. That's awesome. So I was generally excited. I love to talk to people about diet, and I was generally excited about that, but now I've got, you know, some numbers to back up my claims. Let me give you a pro tip, though, Austin. When you go on your interviews, don't the whole time talk about how excited you are about this. the chair of the department will be looking at you like am i going to have a problem with this guy like you're right like like okay this is this is uh it's bringing back some uh some trauma for myself i think um i'm excitable yeah no it's like it's like when i was interviewing for med peds initially i was super excited about diet changes for like lifestyle diabetes stuff like that

And I would talk about it, like how I talk on the podcast. Like, I'm excited about something, you know? And I would get these, like, blank stares back at me by these people who were just like, you realize we just put people on insulin here. Like, we don't have time to counsel them about their diet, right? I got these blank stairs back, right? So, anyways, that's my pro tip. Be careful.

The system may not be ready for your level of excitement about this. Well, it's better to care some than not at all. No, no, I agree. No, I'm excited and I'm with you, but I guess what I'm hinting at, the larger issue, is most people have no idea that these studies even exist. And so if you're listening to this episode and you know anyone in the medical arena, any psychiatrist, any therapist, send them this episode, send them the handout that'll go with it. Austin, I'm plugging Austin's work here. I mean, he literally has worked probably 150 hours on this handout.

Because we've been working, what, six months on this? And we've had multiple iterations. It's been a while. Yeah. You've worked so hard, man. You've worked so hard. And you've learned statistics. And you've learned all this stuff that's going to change your practice forever. So it's like, it's well worth the time. but it is a lot of time. So please, if you share Austin's enthusiasm, send me a kind message and I'll forward it to Austin. That would just be so uplifting for my day if I just get a text from you. That would be so cool.

Or put it in an iTunes review, and I'll share that with Austin as well. Oh, you know what? I think that's so interesting you bring that up. My wife, like, a week ago, she admitted to me. She was like, she works for digital marketing. And a lot of times, like, when her, like, bosses are, like, you know, they give her a really kind compliment or something.

She copies it or screenshots it, and she puts it into something called her smile file. Oh. And I think it's so fun. She's got just this file of texts copied or screenshoted when people have told her that she's done like a really good job or just things that made her feel well. That's really nice. Yeah. And so I just thought I would have to preface that because I was going to tell you I'm going to put those texts in my smile file.

That's really cool. Yeah. You know, even better than like I love the episode, what I really appreciate is like one of my listeners was like, hey, listen to your episode on diet, strength training, made big changes, started looking. twice a week, started doing cardio three times a week, changed my diet to a Mediterranean diet, and I'm feeling one year later, I'm feeling so much better, and I've lost, you know, blah, blah, blah, pounds,

and I'm just feeling great, you know? So once in a while, I'll get a message like that, and that makes me feel like, wow, okay, it's enough. Sometimes a little bit of education is enough, you know? And, yeah, just think about that one mental health provider maybe a psychiatrist who's a little bit like moderate depression. They're like, okay, you convince me, I'll do this, I'll give it a shot.

Six months later, they're feeling a lot better. And then, you know, think about all the patients they impact because they're feeling a little bit better. Right. And on the provider side, too, if there's anything that my favorite study, the brief one showed us is that, like, you don't have to do a lot of handholds. holding, you can just say, hey, there's a whole bunch of resources on this, try it out, and it shows to be effective. Yeah, most people know. I mean, most people have heard the Mediterranean diet helps.

It helps with diabetes, stroke. I remember reading in medical school this really cool study on post-stroke change of just switching to the Mediterranean diet. And I was like, wow, that's a huge change. Like, does aspirin make that big of a change? You know, oh, and then I was thinking like, like something crazy, like more than half of money flowing into like TV and stuff comes from pharma. You know, so like especially like older people watch TV. They're on there.

They're listening to these things. There are no info commercials about diet. You know, the avocado lobby is not doing their job. Okay. So they need some backing. They need to fund me. That's what they need. I could be on there.

Yeah, I think so. I think you do. Be like chocolate, avocados, that's what you need. Okay. Wait before the next quote, Mediterranean pill comes out. Yeah. It's claimed to have all the nutritional benefits of the Mediterranean diet and just one pill. Oh, I love these little, like, vegetable pills.

It's like, we have packed all of the goodness of a vegetable in this pill. It's like, no, you haven't. You have not. You don't have any water in that pill. You don't have any fiber in that pill compared to like eating a serving of kale. You know? Right. Like, it's so funny.

So, yeah, somewhere people are going to try to commercialize and market this thing, right? But it's like, it's almost impossible to. There's just not a lot of money in eating healthy. unless you're like what are those companies you know they they they they they send you the food oh like a pre you know yeah but then even that like it's not a lot of money like you right you go you go to the ICU for one day it's like what 20 30 thousand dollars you go do one day of surgery it's like 100,000 dollars maybe the insurance pays 30,000 dollars like there's no way anyone's going to make that level of money from you changing your diet.

So there's just never going to be the incentive. That's true. There's counter incentives because it's actually easier to eat, easier to eat food. Okay, let's keep you on. Hopefully people enjoy the tangentialness of this intellectual respite from statistical anomalies. Analysis. Yeah.

Yeah, so that was actually the last study I had on, like, verification. Like, you know, like, not specifically verification, but, you know, after this Miles trial, did we have anything else that showed this? So those are the three main studies I had for the Mediterranean diet. And it really just culminated into two big points. Like, these three studies after this Miles trial, what do they say? say. And the first point I really wanted to make was that diet, you can successfully change it, modify it, without intensive or like even regular nutrition consult. Like they gave meal plan

samples and online video instructions in the brief study, and they made changes just with those resources. So like if you Google right now, what is in a Mediterranean diet or just Mediterranean diet, you will probably find like a billion resources that will show you what you can eat. Great, great point. The second being that the changes in your diet. So like if you did that, if you went in Google Mediterranean diet, how do I, like WikiHau Mediterranean diet, how long is it going to take you? And so my second point was changes in diet can yield mental health benefits in a relatively

short period, again from my favorite study showing that in 21 days. you can have rapid positive effects on your well-being. You could go from taking your SSRI for a year, still being moderate to severely depressed, change your diet from WikiHau Mediterranean in 21 days, and possibly be feeling a lot better. Yeah. That's good.

And I would add, it seems like from the longer studies, like longer is better. But I think it's hopeful that there's a quick impact. Right. And even if like one, you know, the study that showed, you know, even after six months that they had positive benefit. So like, you know, say you fall off the horse every once in a while, like that's, you're still going to get improvement if you improve your diet even by small changes. Yeah. Okay. So what's, where do we go next from here? What do we talk about? So after that, I was like, well, you know, it sounds pretty clear what we should do. We should cut out high sugar.

We should cut out high saturated fat. We should eat the Mediterranean diet. And we should cut out all those artificial additives as well. Right, right. Which like, you know, there's a ton of them. Okay. Except for I die 40. I'll never give it up.

People, someone is going to be very concrete and not know that you're joking. I'm joking. Okay. I'm joking that no, I'm joking that someone would think that you weren't joking. I'm joking that red dye number 40 is a staple of my household. I wanted to look at just some other studies like saying, hey, what about some other foods that have improvement in mental health? We're talking about the Mediterranean diet a lot. You know, is there anything else? and I really wanted to talk about your gut microbiome because we hinted on it in the first study that was hinting that ultra-process foods can change your gut microbiome.

And so I wanted to look at a study, and so I've got one. Great. I'm excited about the gut microbiome. And I think it's more complicated than just take a pill. But go ahead. Let's talk about it. Let's get into it. What did this study show?

I think so, too. So we got this study, and I love the name of it. It's called the gut feelings trial. It was spearheaded by Frage, I want to say, at all in February of 2023. So this was just a few months ago that this study came out on gut feelings. So this is a randomized control trial among one of the first of its kind, so they claim, to look at the effects of biotics on mental health. And so when I say biotics, I, mean prebiotics, probiotics, and symbiotics, which we will get to the difference of all those later. They had this study that recruited 119 participants aged 18 to 65, so a lot of the same age of the same age groups that we've previously seen, specifically selected on criteria like psychological stress, a low prebiotic fiber intake, and no recent use of fermented prebiotic products or like antibiotics. You can't have used PPI's, no Nseds, no psychics. psychotropic medications, no immunosuppressants, basically anything that's going to clear out your gut

or majorly alter your gut microbiome, you couldn't have done it. So they took these participants, and they divided them into three, maybe four, I think it's four actually separate groups. They have the probiotic group with 30 people, the prebiotic diet with a placebo supplement, 28 people, the symbiotic group containing a prebiotic diet with a probiotic supplement with 32 people and a placebo group with 28. So it's here that I'll go ahead and say what the differences between these are because it can get really confusing when you start saying biotic four times. Prebiotics are just basically high fiber foods. They're foods for the gut microbiome. There are foods that the gut microbiome feed off of.

Probiotics, that's giving you an actual like, hey, here is 100,000 colony forming units of whatever microbiota here will give it to you in your gut. And a symbiotic is doing both of those. Okay. So they had every group take two capsules twice daily, once in the morning and one in the evening with food for eight weeks. They either had placebo capsules or probiotic capsules that were very similar to each other, indistinguishable between like taste, texture, appearance. The participants aside to the prebiotic diet group were given specific instructions to consume seven or more servings a day of prebiotic rich foods.

These were foods like watermelon, whole wheat, chickpeas, onion, oats, my favorite, garlic and asparagus. The participants in the diet group were also given examples of high prebiotic foods and a hamper containing these to kind of kickstart their adherence, kind of like we saw in the previous Mediterranean studies. They were also given an instructional video that outlined the specifics of the prebiotic diet and how to incorporate it into their daily meals. Whereas everybody in a non-diet group to kind of control for watching a video, they watched a video that focused on their supplements and provided information about the overall study design.

So, the primary outcome measure in this study was total mood disturbance score, and they assessed this using the, this is a mouthful, profile of mood state's adult short form second edition, POMS 2SF. So this POMS is a self-report questionnaire. It measures psychological distress experienced over the past week. It basically looks like a bunch of words associated with different feelings of psychological stress and like you can either say how much you associated with that feeling during each of the days of the week. A decrease in the total mood disturbance score indicates an improvement in a mood and more and higher values reflect a more negative mood state. So an inverse relationship. If you go down in total mood disturbance, you have an improvement in

So at the end of the eight-week study, there was moderate evidence indicating that the prebiotic diet led to a reduction in mood disturbance compared to the placebo group with a mean difference in total mood disturbance of 6.97, which corresponded to an effect size of 0.60. Interestingly, there was little evidence, and it wasn't statistically significant, to show that the probiotic or the symbiotic groups had a significant impact on reducing mood disturbance compared to the placebo, which is wild and weird that the prebiotic group did, but the symbiotic group adding a probiotic to that prebiotic diet didn't do anything. I actually don't find this weird at all because I think the big thing is the symbiotic.

It's the prebiotic. It's the fibro. It's the fiber, eating lots of real food. that will cause not this little pill to multiply in you more, but you have, what, like a trillion? I don't know, like, so you have so much, so much life already in there, right? That, yeah, feeding that healthy bacteria, good food every day for it, you know, is going to help you. Right.

And I don't think like 100,000 colonies is going to make a dent in your total gut biome profile very much. But go ahead. Right. And I don't know if that was the colony units they used. I just threw that out there. But I guess I don't know enough about the gut microbiome. But in my head, I was like, you know, if you have this very fibrous, rich food that's helping, like you said, I felt like a little pill wasn't actually going to change that benefit.

but it seemed to have hampered the benefit. You know what I mean? Like the symbiotic group didn't have a big change, but the prebiotic group did. Well, they had a, it was the same as the prebiotic group, right? No. The change was the same. So the symbiotic group had an effect size of like 0.19. 0.19 compared to the prebiotic group that had an effect size of like 0.6.

Right. So the prebiotic group, that effect size, was based off a comparison between the prebiotic group and what group? The prebiate group and the placebo group. Which got nothing. No change, right? Just a sugar pill? Yes, which just got a placebo pill. Okay.

And then you're saying the symbiotic group compared to the... Compared again to the placebo group. Really? Okay, so I can see why it's confusing for you. They did have a few, the authors, they were like, hey, you know, like, what's going on? Like, we thought that the symbiotic group would do the best, and we thought that these other groups would do better but not best. And so they were like, why? One possible explanation, they spoke about the competition between native bacteria and the probiotic bacteria that they introduced.

Hmm. So the probiotic, that the pill actually made, made them worse. Right. So, yeah, the prebiotic, the prebiotic diet group was the only one that statistically, like, significantly had a difference compared to the placebo. The symbiotic did not. Okay, I'm pulling up the actual study. If you're on YouTube, you can see this. Okay, so we're looking at table two. The prebiotic is what did the best. Okay. Because it's so, it's like, I would expect the prebiotic to do just as well as the prebiotic plus the probiotic. Like if the probiotic wasn't, that's what they, wasn't doing very much. That's what I would expect. That's what the authors also, they were like confused. And so, again, they had several possible explanations.

But they, the biggest thing was that they cautioned, like, concluding that the prebiotic diet was like the biggest thing responsible for the positive outcomes because the symbiotechings. because the symbiotic diet group didn't do any better than the placebo. Yeah. I mean, this kind of like on my podcast before I've talked about the benefit of eating highly fermented foods or fermented foods, not highly, but fermented foods, like kefir, kefir or kimchi, sourcrow, stuff like that. So coming into this episode, I would have said, eat real fermented food. and eat prebiotics, you know, things with high fiber or stuff like that.

But what we're taking away from this article is that for some reason, this group that ate this probiotic, which, you know, had, I wonder what actually was in that probiotic, by the way. Do you remember? So the probiotic formulation, which was provided by this biocyticals company, delivered 12 billion colony forming units per capsule containing bifidobacterium bifidum, 2 billion colony forming units of bifidobacterium animalis, subspecies lactus, and 1 billion colony forming units of bifidarium longum, and the list goes on of bifidarium lactobacillus.

Okay. So, I mean, you know, what does this, tell us prebiotics are important. This particular grouping of probiotics was not as helpful. My prior recommendations on fermented food probably still stands, but prebiotics also being important, prebiotic diet just tends to be more Mediterranean as well if you look at what they're actually recommended. Right. Fibers. Fibers, yeah.

Legumes, whole grains. Absolutely. Okay, let's keep going. So now are we going to talk about specific foods that we like? Yeah, I've got a couple of studies that I think would be really fun here. Okay, let's go. So I know you wanted to talk about chocolate. So we're doing it.

We're talking about chocolate. Yes, I'm 100% convinced that chocolate is very important. No, go ahead. Tell us. So we got, I got two. two studies on chocolate, actually. Do you want to do the both of them or just one? Probably both of them.

Probably both of them? Okay. So we've got a cross-sectional study by Jackson et al in 2019. He wanted to look at, or they wanted to look at it, I should say, the relationship between chocolate consumption and depressive symptoms. So they have 13,000 participants. These participants, they gathered data because they participated in the national health and nutrition examination survey.

So it was found in this large survey that 11.1% reported consuming chocolate based on two 24-hour dietary recalls. So 11% out of the 13,000 people reported consuming. And within that subset, it was found that 12.1% reported consuming dark chocolate specifically. So what did they actually find? They said that those reported, those that reported consuming dark chocolate showcased a significantly lower odds. Um, 0.30 odds ratio of experiencing clinically relevant depressive symptoms. That's, that's crazy.

Yeah. I'm like, are you, are you like, are you literally pulling out the only study that showed such a large odds ratio for positive impact? because you know that I want you to find this study for me. Like, how many neutral studies did you have to can to find this one study, you know? There's a lot of studies about chocolate. This was one of the biggest, like the biggest end, though. Okay. Okay.

So you have it from Austin, Coleman, MS4, eat some dark chocolate and feel good. Feel good that you're doing that. I will say, though, that... But based on this study, it has to be like a dark chocolate. Yes. And, but what's wild about it is that the highest quartile of chocolate consumption, they had between 104 and 454 grams a day, which is like just this big range. And I want to let you know that 454 grams is a pound.

It's a pound of chocolate. I was in this study. I was in it. The highest quartile of these guys exhibited a 57% reduction in the odds of depressive symptoms when compared to those who reported no chocolate at all. So I think that was just for like regular, like regular, I don't think they specified dark chocolate, but that's like up to a pound of chocolate for these guys. Okay. Wow. I'm so, so true story for a while because I knew dark chocolate was good for you.

was recording how many grams a day I was eating. It's embarrassing. I could show you that data, actually. I could pull that data up. Let me see if it's handy. While you're pulling up that data, I want to be really clear that it is not my official recommendation to eat one pound of chocolate per day for your overall health. No. That is going to be not a recommendation. No, I can't find it. Okay, no. Of course, of course not, because this is like, this is like, yeah, this is just something to consider in the big picture of your diet, you know, eat a little bit of dark chocolate, and think about this episode. Think about how that is probably helping you. Okay. Yeah. And so I've got another, I've got another trial on it, another study, because after that one, I was like, well, what does. dark chocolate mean? You know what I mean? There's so many different percentages.

You know, like, are, am I just going to like blanket, say, eat some dark chocolate? So I wanted to look at the further end of that. And so I've got a study by Shin at all in 2022 that also wanted to look at dark chocolate consumption on mood. So they had a randomized control trial, 48 participants aged between 20 and 30 years. These were individuals who did not regularly consume sweets like chocolate or candy. They didn't have diabetes. They didn't have significant depression. And they had not undertaken any interventions that could affect their gut microbiome because they also had some like secondary outcome measures about gut microbiome and dark chocolate. And so they were divided into three intervention groups,

85% dark chocolate, 70% dark chocolate and a control group. The individuals in the chocolate groups were instructed to consume 10 grams of chocolate three times per day for a duration of three weeks. So that's 30 grams of chocolate a day, nowhere near a pound. That is a manageable amount of chocolate. It's 30 grams. It's not enough. It's not enough in my mind, from my own personal preference. It's manageable. But it may be more manageable for someone who doesn't like dark chocolate. Okay, good. Listen, I love dark chocolate. So don't come at me. I don't weigh it out. So I have no idea how much I eat. The control group, they didn't get any chocolate. and they were told to come back in three weeks.

So no active control here. Primary outcome measure was the positive and negative effect schedule. So again, this is like 20 different emotions over the past week. How much did you feel these emotions? The study findings revealed that there was no significant impact on positive effect with the consumption of dark chocolate. So dark chocolate didn't like increase the positive effects, which I don't know how that's possible.

I don't know. There's an error. There's an error in this study already. we could find the air. The group that consumed 85% dark chocolate showed a significant decrease in negative affect

and the change in negative affect following the intervention was not significantly different in the group that consumed 70% dark chocolate compared to control group. So what we kind of found here was that

nobody had a brighter more positive affect from the dark chocolate chocolate, which again, I don't know how that's possible. But there was a significant decrease in negative emotions with 85%, but not 70%. In this one study. I think the first study was a little bit more vague on like what dark chocolate was. Is that, is that correct? Right. Yeah. Yes. But I mean, it's saying basically darker, darker is better. Obviously, sugar is not going to be what makes you have a therapeutic benefit, you know, if you're eating, like, a ton of sugar.

So it's like the dark chocolate. I mean, I don't know if I just don't, if I don't have a refined palate or not, I don't know. But, like, once you start getting to 90%, you might as well just go into your backyard and get some dirt. You know, like, I don't know if it's going to. 85 is like, it's like, it's like pretty, pretty dry. Okay. That's pretty better. Shout out.

You know, the OBGYN or the OBE episode. I recently did. I recently did episode 184 was on pregnancy planning. Kara Jacobson sent me some chocolate after the episode. Shout out to Kara. What percent? I'm not going to say the specific percent, but it was really good. I see it as milk chocolate.

No, it wasn't milk chocolate. It was dark chocolate. But it was the thoughtfulness. It's like, I've never... Even worse, white chocolate. Okay. for the record, I don't think I've ever received a thank you with dark chocolate from a medical student. It's now expected.

Austin. After this episode, right? After this episode, yeah, don't object. From this episode, and there on now, it's expected, but not for this one, right? For you providing this information on dark chocolate has been enough. It's been enough. It's satisfied my... My ideas are paid.

It satisfied my gratitude. Okay. We got one more study to get to you guys. Then we're going to wrap it up. Yep. I may need to do a deep dive on dark chocolate after this. So if you're a med student and you like dark chocolate, and you want to look at this with me and you want to do 150 hours on dark chocolate, let me know. Someone out there probably does. Just make sure to eat somewhere between 100 and 400 grams of chocolate today while you're doing it. So no joke. I had a friend come from California, my favorite chocolate,

places out there. So he flew out to Florida to visit me and he brought me 14 pounds of chocolate. And I think over the next four months I'd eaten all of them or given them away. Like as like, like you know you reached friend Nirvana if I've given you a pound of dark chocolate. Yeah. And that's not like a small amount of chocolate. It's not 14 pounds. It's quite bad. So you can calculate that. The way that I say it is like, Freud used to sit there with a cigar in his mouth, you know, while they saw patients. Sometimes I sit there with dark chocolate in my mouth. It's like it helps me focus.

That's a plus, yeah, I mean, yeah, do it. I think if there's anything from these studies, it's that vaguely, please eat dark chocolate. Okay, let's keep going. So I just got the one more study. I was going to look at, you know, I know you requested chocolate, but then I was like, man, I should do one. One that I like, I wanted to do like oats or avocado or something, but then I was like, no, those are just going to definitely be good for you. So I wanted to look at coffee. Okay.

Because I'm a little bit of a coffee guy. I don't drink it every day, but I love the process. Oh, yeah. I mean, you push your own, you press your own coffee at a certain pressure. It's like a hand-press espresso. It's true. So I've got a coffee guy who roses beans, and then I hand-grind them. And then I put it in my manual espresso machine and I press it down.

That says a lot about you. It's really, yeah, it's really fun. All right. So there's a lot of studies examining the association between coffee consumption and depression. But a lot of them that I looked at were just like observational. And they didn't like control for a lot of confounding variables. So I was like, man, I just kind of want to find a pretty good study on coffee. So I did.

I found one. is by Navarro et al in 2018, and specifically wanted to look at coffee consumption on depression while accounting for an adherence to the Mediterranean diet. So they used a subset of participants from this cohort study, the Sun Project, which was a prospective cohort designed to investigate the association between diet and chronic diseases. And basically, everybody in this project were already eating like a Mediterranean-style diet anyway. And so they controlled for that, which I thought was really fun because we just spent a really long time talking about the Mediterranean diet. So they had a selected sample of these participants in the previous study that were free of a

depression diagnosis or antidepressant use at the beginning of the study and within two years of follow-up. So the participants were followed for an average of 10 years, and then they wanted to compare the highest and lowest categories of coffee consumption. And it was observed that the individuals who consumed at least four cups of coffee per day, had a 63% lower risk of depression compared to those who consumed less than one cup per day, but unfortunately it was not statistically significant. The P value was only 0.22.

And so I really wanted to come on here and be like, hey, everybody like start chugging and drink some, you know. Yeah. It's so nice to feel, you know, data validated for the way you do something, right? Yeah. I wasn't, though. Well, the problem is, in this study,

is that they didn't have you squeezing the coffee. I know. I would... Honestly, when I got here, though, too, I was like, man, it's a good thing that it wasn't exactly positive because I could never get to this amount of coffee, like the highest and lowest quartiles.

Like, I don't even drink one a day. So, like, getting up to four cups of coffee per day, I don't think I could like do myself or recommend. Right. Yeah. Okay. So what, however, is there a however here? Well, there is a little bit of a however.

So it wasn't statistically significant, but I wanted to talk about how like, you know, the coffee may not have had much of an impact, but they looked at these 14,000 individuals with a remarkably low incidence of depression. And you know what they all did? No. they were all already eating Mediterranean style. Oh, really? So I just really, I wanted to revalidate what I've been talking,

what we were talking about before. I couldn't get my coffee validation, but, you know. See, so some of you were listening to this, and you're like, okay, how does this possibly relate? Right. Coffee, come on. Like, how does this? But we got you.

We got you really good because this study, little did you know, validated our point of the Mediterranean diet. Okay. It was sneaky. It was really sneaky. That's all I got. That's a good ending. That's a good ending.

Okay, guys, who wants Austin to come back after investing 150 hours in dark chocolate? Let's go. I'm going to need a lot of coffee and dark chocolate with that. Austin may need to be paid, so if there's a donor for the next dark chocolate episode, let me know. All right. No, I'm joking. I'm joking, but I'm not joking. I'm sure Austin would do it if he was paid.

Somebody's got to do the science about this dark chocolate. I may have to do it myself. I may like... I need a large randomized control trial. It's like one of those things I don't really want to be proven wrong though, you know? Like I want to be in blissful ignorance as I'm my dark chocolate, you know? I think we should just listen to the vagueness of the first Jackson-Ed-all study. It's a bigger study.

So like that's... It is, yeah. Something about like if you're super... if you're super high intellect, you're better at grabbing the details that support the worldview that you want to support. Have you heard that? Oh, like a confirmation bias? Yes. So if you, if you're higher IQ, it doesn't mean that you're going to necessarily have wisdom and know the truth. It just means that you're going to be that much better at confirmation bias. Good to know. That's upsetting to hear. No, and I think it's actually really good to know because, I mean,

you'll meet incredibly smart people that think very interesting things. And it's like usually they came to that conclusion based off of things that were not actually studying it with an open mind. They started with like some sort of bias and then they looked for all the data to confirm it. So what I'm hearing is that you being a man of high intellect have a lot of confirmation bias. I'm warning my audience that my confirmation bias may bias a future episode on dark chocolate. No, but I'm also teaching people that just the importance of confirmation bias, you know, and how, you know, you could listen to this episode and you could get this far and you could be like, well, my confirmation bias says that it's not really about diet. That's not important at all. I'll get my CME, you know, we offer. see-me. I'll get my CME for this episode, but I'm not going to really change the way I eat or

recommend it to other people. It's like, see, but you maybe, maybe your prior, you know, maybe you're approaching this episode with confirmation bias that it's not important. And so, it's like, yeah, we have to have an open mind. So I always tell medical students when they work with me, prove me wrong, don't look for what I'm looking for, just look at what are the best studies, what does it say? Let's look at the day. Let's look at the day. data, and I try to not bias them one way or the other for what direction I want them to go in, because I want to know the truth, you know, and be challenged. So it's good. Okay, with that, we will end the episode. Try to look at your highly processed foods and see how you can reduce it.

Try to insert some good olive oil, some good Mediterranean food, some omega-3s, and we will leave it there for today. Plus or minus one pound of dark chocolate. Oh, yeah, please, please eat at least 30, what is it, 30 or 50 grams? That's like... It was, yeah, the second study had 30 grams a day. Yeah. It's a low bar.

I'm gonna order some right now. All right.