Emina Rovcanin

HUN 3800 Nutrition Science Research and Ethics

Assignment 6 Literature Review Paper
Does eating a more nutrient dense diet decrease the prevalence of
depression/anxiety in middle aged women?

Introduction
This paper will focus on whether a Mediterranean diet (diet with increased intake of
fruits, vegetables, fish and legumes, and decreased intake of Trans fat and unsaturated fat) has
an inversely related correlation with depression in middle aged women as opposed to a
Western diet (diet high in red meat, processed food, trans fat and alcohol).
This paper will begin with explaining why the topic of a nutrient dense diet and its
influence on depression and anxiety is important to me. It will further describe depression in
general and its significant impacts on women ages 30-50. It will also illustrate the
Mediterranean diet in detail and connect the affects it has on depression in middle aged
women. Furthermore, it will depict the Western diet and how it affects the prevalence of
depression in middle aged women.
Why I chose this topic?
Mental health problems such as bipolar disorder, anxiety and depression are prevalent
in my family. Since all of my family lives in Bosnia and Herzegovina the only person that I see
the effects of it on is my mother. One of the oldest memories I remember is an anxiety attack
my mother had when I was 6 years old. The only reason this memory is so fresh in my mind is
because it can happen in the blink of an eye. One minute everything seems to be fine, normal
conversation, even laughter is all of a sudden halted because one small thing was said that was
taken the wrong way. The anxiety attack included behavior such as unstoppable sobbing, short
of breath, and physical harm to her and others. I am the oldest sibling of three so I always felt
responsible to take a stand and take care of the situation as best as I could preventing my

brother and sister from the harm, whether it was physical or verbal. As I grew older I learned
what would cause these episodes. People diagnosed with depression and bipolar disorder
suddenly feel no self-worth and as if no one in the world cares for them. Every problem in the
world suddenly becomes a heavy burden on their shoulders and they become severely
overwhelmed. This feeling sometimes forces them to take their pain out on others, and in my
families case I took the heat for the sake of my siblings. My mother has been taking medication
for her illness since I can remember and the only thing the doctor has done for years is increase
her dosage. I believe that not only does a change in the home and work environment have an
impact, but a well-balanced diet does as well.
Main Point One: Depression in Women ages 30-50
Depression is a state of mind that alters your mood to a state of sadness and loneliness.
It is not taken lightly by medical practitioners. Having depression is an illness that affects
behavior, mood, physical health and feeling. Other serious symptoms that come hand in hand
with depression are poor concentration, insomnia, poor physical health, thoughts of suicide,
loss of appetite and feeling of guilt. Some symptoms of depression that are more prevalent in
women are anxiety, weight increase, oversleeping and very expressive anger and hostility.
One in ten Americans experience depression each year. Women experience twice the
rate of depression as men with numbers estimating at 1 in 8 women trial with depression each
year. The reason for this gender gap associated with depression is a combination of biological,
genetic, psychological and social factors.

The biological factors may include reproductive events in the females life. Selfproclaimed depression is significantly higher after the birth of a child and during the
menopausal period. The period after child birth that is linked to depression is referred to as
post- partum blues. Other factors that may cause depression after childbirth are; stress,
stress can significantly increase while caring for a child and the financial responsibility is
increased as well.
The genetic factors that link women to greater prevalence of depression include the
forms of depression that run in families. There is a 25 percent correlation of second generation
depression if a first degree relative suffers from this disease. A first degree relative would
include the mother, father and siblings.
Psychological factors carry the most contribution to the gender gap of depression. Some
of these factors include sexual discrimination, stress of many responsibilities such as work and
family, sexual and physical abuse and lack of support. The state of mind of an individual also
plays a major role in depression. If a person tends to be very pessimistic or have a low selfesteem their tendency to be depressed is higher. Many studies in Amish communities of
eastern Pennsylvania have shown equal rates of depression in men and women, suggesting that
the equality in workloads and respect are what minimizes this gender gap.
In contrast with the large gender gap between men and women and the
prevalence of depression, there does not seem to be a grand difference in how the treatment
affects the two genders. Common treatments such as personal therapy, antidepressants, bright

light therapy, acupuncture and nutritional supplements are noted to have the same effects on
men and women.
Main Point Two: What is the Mediterranean Diet and what are its effects on women
The Mediterranean Diet is based on the dietary patterns of Crete, Greece and southern
Italy around the 1950s which was a time when disease and illness rates were at an all-time low.
The Mediterranean dietary patterns are referred to as the gold standard by Oldways, the
Harvard School of Public Health and the European Office of the World Health Organization. The
people of the Mediterranean region are noted to be very active, exercise often and enjoy meal
time with family and friends. The main portion of their meals includes nutrient dense foods
such as fruits, vegetables, whole grains, olive oil, beans, nuts, legumes, and seeds. The largest
source of protein includes fish and seafood. These foods are eaten at least two times per week.
The foods that the diet includes moderately include poultry, eggs, cheese and yogurt. Red meat
and sweets are at the top of the food pyramid meaning they are consumed rarely. Water is the
most consumed beverage and when including alcohol wine is best recommended in
moderation.
The Mediterranean diet is low in saturated fats and Trans fats, but high in Omega 3 fatty
acids and folate. The use of virgin olive oil, fish, nuts and vegetables adds to many important
nutrients to the diet. The Journal of Human Nutrition and Dietetics did a cohort study on
nutrient prevalence in diets and the risk of unipolar depression in adults. They found that the
increased amount of folate intake reduced the prevalence of depression after in a checkup
eight years later. The reason folate is inversely related to the prevalence of depression is

because folate is linked to the regulation of neurotransmitters. An adequate intake of folate in

the diet increases the number and rate of neurotransmitters in the body. Folate is highly
recommended for women because it is a B vitamin that is linked to prevent neural tube defects
and provides healthy fetal development. Most women are not informed on the importance of
folate until they see a physician due to child bearing. This low intake of folate leads to increased
risk of depression in women.
This same study suggests that there is an inverse association between the intake of
monounsaturated and unsaturated fatty acids with depressive symptoms. This study also
concluded that those who consumed fish and seafood in their diets were at a 30% lower chance
for depressive episodes than those who do not consume fish. The consumption of fish adds to
the levels of Omega 3 polyunsaturated fat intake. Diets lacking omega 3 polyunsaturated fats
lead to interference in neural function. The human brain is composed of lipids, 35% of which
are polyunsaturated fatty acids. Neurotransmission relies on the fluidity of the cell membranes
of the neurons. Neurons composed of membranes that lack polyunsaturated fatty acids have
trouble sending out signals to the brain. This lagging of neurotransmission affects mood and
send out less feel good signals and signs of depressive symptoms start becoming apparent.
The University of Quebec did a study and compared to a placebo, Omega 3 supplements were
shown to reduce the signs of moodiness in menopausal women.
A study referenced as Dietary pattern and depressive symptoms in middle-age
assessed that those with the highest intake of whole food such as fruit, vegetables, fish were
less likely to be depressed at the time of the planned follow up two years after the diet was

assigned. The group that followed the Mediterranean diet shows a 37% less likelihood of selfreported depression symptoms. To contrast, those with high intakes of processed foods,
notably; sweetened desserts, chocolates, fried foods, and processed meat were more likely to
be depressed at the time of follow up. Women are more likely to intake sweetened foods, and
desserts because of cravings before the menstrual cycle and during menopausal periods than
men. This increase in saturated fats and processed foods increases depressive symptoms.
The Mediterranean diet has meals based mostly on fruits, vegetables and grains. The
increase of fruits and vegetables in the diet shows an inversely related relationship to
depressive symptoms. A reason for this is because fruits and vegetables are rich in
carbohydrates and vitamins. The density of carbohydrates triggers the release of insulin in the
body which is used to help blood sugar be converted to energy. For the conversion to be
complete the body triggers tryptophan to enter the brain which affects neurotransmitter levels.
Higher levels of neurotransmitters in our body positively affect our mood, energy and decrease
depressive symptoms. Women of a healthy weight range have a higher body fat percentage
than a male of healthy weight range. This means more insulin is needed to convert blood sugar
to energy. This need for more carbohydrates and vitamins for healthy function in women shows
why the prevalence of depression is higher in women than it is in men.
Main Point Three: What is the Western Diet and what are its effects on depression in women.
The Western diet is a diet high in red meat, processed foods, desserts, fried foods,
refined grains, sugars, sweeteners, alcohol and Trans and saturated fats. This diet is more
prevalent in developed countries, number one being the United States. The Western diet is also

referred to as the Standard American Diet. This diet has macronutrient percentages such as
50% carbohydrates, 15% protein and 35% fat. Instead of consuming complex carbohydrates,
this large percentage of carbohydrates is almost entirely made up of sugary foods. Also a red
flag concerning the Western diet is the percentage of fat intake is 5% more than the
recommended intake of 30%.
It is not a coincidence that the United States, home of the Western diet has the largest
prevalence of depression and other diseases not just concerning mental health. The Western
diet includes the most Trans and unsaturated fats than any other diet in the world. This poor
nutrition is linked to the rate of depression being the highest in the United States than
anywhere else in the world. Trans and unsaturated fats are referred to as pro inflammatory
cytokines. These cytokines interfere with neurotransmitter metabolism which decreases
tryptophan levels. Low tryptophan levels decrease the neural tube function. Inadequate neural
tube function leads to birth defects such as spine bifida and poor brain development in the
fetus. This relates to depressive symptoms in middle aged women because the birth of
unhealthy babies may be directly related to their diet before conception and during pregnancy.
Mothers self reportedly feel guilt and show depressive symptoms if their babies are born with
health problems.
Contrasting with the intake of monounsaturated fats in the Mediterranean diet
increasing neurotransmitter function, the saturated fats in the Western diet decrease and slow
the function of neurotransmitters. Neurotransmitters directly affect hormones that produce
endorphins in the brain that promote the decrease in symptoms of depression. The Western

diet slows the production of these endorphins which shows the correlation of depression and
the United States.
To conclude, the Mediterranean diet shows an inversely related correlation between
depressive symptoms while the Western diet has a direct correlation. The Western diet has
high intakes of Trans and unsaturated fats, processed foods, red meat, sweeteners and sugar.
These foods have high pro inflammatory substances and these interfere with neurotransmitter
metabolism which increases depression in middle aged women. To apply this to dietetic
practice it is important to introduce patients to the Mediterranean diet. Educating them on the
importance of increasing intake of fruits, vegetables, legumes, fish and poultry to reduce
depressive symptoms will become vital. Easing them into a new, unfamiliar diet pattern may
not be simple but it is important for a healthy lifestyle. Not only does the Mediterranean intake
of food positively affect health but their exercise pattern and sharing most meals with loved
ones does as well.

References

1. http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=20dfc818-eaed-4d69-9f5f13ca9c3e3d45%40sessionmgr4&vid=3&hid=4

Quirk S, Williams L, Brennan S, et al. The association between diet quality, dietary patterns and
depression in adults: a systematic review. BMC Psychiatry [serial online]. August 2013;13(1):122. Available from: Academic Search Complete, Ipswich, MA. Accessed October 20, 2013.
Abstract: Background: Recent evidence suggests that diet modifies key biological factors
associated with the development of depression; however, associations between diet quality
and depression are not fully understood. We performed a systematic review to evaluate
existing evidence regarding the association between diet quality and depression. Method: A
computer-aided literature search was conducted using Medline, CINAHL, and PsycINFO, January
1965 to October 2011, and a best-evidence analysis performed. Results: Twenty-five studies
from nine countries met eligibility criteria. Our best-evidence analyses found limited evidence
to support an association between traditional diets (Mediterranean or Norwegian diets) and
depression. We also observed a conflicting level of evidence for associations between (i) a
traditional Japanese diet and depression, (ii) a "healthy" diet and depression, (iii) a Western
diet and depression, and (iv) individuals with depression and the likelihood of eating a less
healthy diet. Conclusion: To our knowledge, this is the first review to synthesize and critically
analyze evidence regarding diet quality, dietary patterns and depression. Further studies are
urgently required to elucidate whether a true causal association exists [ABSTRACT FROM
AUTHOR]

2. http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=53db5c01-0b6b-4d11b4e6-627e8e693440%40sessionmgr12&vid=3&hid=4

da Silva Germano P, Silva D, Soares G, dos Santos , Guedes R. Hypercaloric high-lipid diet and
brain development: Effects on cortical spreading depression in adult rats. Nutritional
Neuroscience [serial online]. November 2013;16(6):275-281. Available from: SPORTDiscus with
Full Text, Ipswich, MA. Accessed October 20, 2013.
Abstract: Nutritional conditions early in life constitute one of the environmental factors that
can influence brain electrophysiology, as evaluated through the phenomenon denominated as
cortical spreading depression (CSD). Objective To evaluate the effects of hypercaloric diet
intake in different phases of life on CSD features in adult rats. Methods Newborn Wistar rats
were suckled by dams fed a high-lipid (cafeteria) hypercaloric diet during the lactation period.
After suckling, part of the pups remained in the high-lipid diet until the end of the experiment
in adulthood (group 'full-life' FL), and the other part received the control (lab chow) diet (group
L). A third group received the hypercaloric diet only at adulthood (group Ad). When the animals
reached 90-93 days of life, CSD was recorded. Results CSD propagation velocities (in
mm/minute) and CSD amplitudes (in mV) were reduced (P < 0.05) in the groups L (2.77 0.07
and 7.1 2.0 for velocity and amplitude, respectively) and FL (3.05 0.17 and 8.5 1.9), but not
in the group Ad (3.36 0.11 and 10.7 2.0), in comparison with a control group (C), fed the lab
chow diet during the entire life (3.52 0.18 and 10.8 2.2). Discussion CSD velocity changes
observed in adulthood were associated with the hypercaloric dietary treatment during brain

development, constituting evidence in favor of permanent or at least long-lasting

electrophysiological effects related to the prevailing nutritional status during the period of
brain growth spurt. ABSTRACT FROM AUTHOR

3. http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=53db5c01-0b6b-4d11-b4e6-

627e8e693440%40sessionmgr12&vid=3&hid=4
nchez-Villegas A, Martnez-Gonzlez M, Serra-Majem L, et al. Mediterranean dietary pattern
and depression: the PREDIMED randomized trial. BMC Medicine [serial online]. October
2013;11(1):1-12. Available from: Academic Search Complete, Ipswich, MA. Accessed October
20, 2013.

4. http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=53db5c01-0b6b-4d11-b4e6-

627e8e693440%40sessionmgr12&vid=3&hid=104
Sanchez-Villegas A, Martnez-Gonzlez M. Diet, a new target to prevent depression?. BMC
Medicine [serial online]. March 2013;11(1):1-4. Available from: Academic Search Complete,
Ipswich, MA. Accessed October 20, 2013.
Abstract: Background Nutrition may be a risk factor for unipolar depression. We aimed to
review the association between dietary variables and the risk of depression. Methods Fifteen
databases were searched up to May 2010. Only longitudinal studies for which outcomes were
unipolar depression and/or depressive symptoms in adults were eligible for inclusion. Eleven

studies were included and critically evaluated. Participants were in the age range 18-97 years
and the study sample size was in the range 526-27 111. Follow-up ranged from 2 to 13 years.
The diversity of dietary variables and nonlinear associations precluded formal meta-analysis
and so a narrative analysis was undertaken. Results Variables inversely associated with
depression risk were the consumption of nutrients such as folate, omega-3 fatty acids and
monounsaturated fatty acids; foods such as olive oil and fish; and a diet rich in fruits,
vegetables, nuts and legumes. Some of these associations varied by sex and some showed a
nonlinear association. Conclusions At the study level, weaknesses in the assessment of
exposure and outcome may have introduced bias. Most studies investigated a cohort subgroup
that may have resulted in selection bias. At the review level, there is a risk of publication bias
and, in addition, narrative analyses are more prone to subjectivities than meta-analyses. Diet
may potentially influence the risk of depression, although the evidence is not yet conclusive.
Strengthening healthy-eating patterns at the public health level may have a potential benefit.
Robust prospective cohort studies specially designed to study the association between diet and
depression risk are needed. ABSTRACT FROM AUTHOR

5. http://ehis.ebscohost.com/eds/detail?vid=2&sid=53db5c01-0b6b-4d11-b4e6-

627e8e693440%40sessionmgr12&hid=104&bdata=JnNpdGU9ZWRzLWxpdmU%3d#db=r
zh&AN=2011532631
Appelhans B, Whited M, Pagoto S, et al. Depression Severity, Diet Quality, and Physical Activity
in Women with Obesity and Depression. Journal Of The Academy Of Nutrition & Dietetics [serial

online]. May 2012;112(5):693-698. Available from: CINAHL Plus with Full Text, Ipswich, MA.
Accessed October 20, 2013.
Abstract: Background: Recent evidence suggests that diet modifies key biological factors
associated with the development of depression; however, associations between diet quality
and depression are not fully understood. We performed a systematic review to evaluate
existing evidence regarding the association between diet quality and depression.
Method: A computer-aided literature search was conducted using Medline, CINAHL, and
PsycINFO, January 1965 to October 2011, and a best-evidence analysis performed.
Results: Twenty-five studies from nine countries met eligibility criteria. Our best-evidence
analyses found limited evidence to support an association between traditional diets
(Mediterranean or Norwegian diets) and depression. We also observed a conflicting level of
evidence for associations between (i) a traditional Japanese diet and depression, (ii) a "healthy"
diet and depression, (iii) a Western diet and depression, and (iv) individuals with depression
and the likelihood of eating a less healthy diet.
Conclusion: To our knowledge, this is the first review to synthesize and critically analyze
evidence regarding diet quality, dietary patterns and depression. Further studies are urgently
required to elucidate whether a true causal association exists.

6. http://ehis.ebscohost.com/eds/detail?sid=53db5c01-0b6b-4d11-b4e6-

627e8e693440%40sessionmgr12&vid=3&hid=104

Sanhueza C, Ryan L, Foxcroft D. Diet and the risk of unipolar depression in adults: systematic
review of cohort studies. Journal Of Human Nutrition And Dietetics: The Official Journal Of The
British Dietetic Association [serial online]. February 2013;26(1):56-70. Available from: MEDLINE,
Ipswich, MA. Accessed October 20, 2013.
Abstract: A simple and relatively inexpensive procedure to obtain 90% eicosapentaenoic acid +
docosahexaenoic acid concentrates from sardine oil involved a two-step winterization of the oil
(10 and 4C), followed by saponification and selective precipitation of saturated and less
unsaturated free fatty acids by an ethanolic solution of urea. Antioxidant effects of butylated
hydroxytoluene, d/--tocopherol, and two natural antioxidants, quercetin and boldine, added
to the concentrate (0.5% wt/vol), were compared in the Rancimat at 60C. d/--Tocopherol was
unable to inhibit concentrate oxidation. Butylated hydroxyanisole and butylated
hydroxytoluene had induction periods of 1.71.8 h compared to the control (1.0 h). A mixture
of quercetin + boldine (2:1 w/w) significantly increased the induction period to 4.5 h. Reprinted
by permission of the publisher.