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Nutrition’s Role in Treating Anxiety and Depression in College Students

Introduction:
According to Anxiety and Depression Association of America (ADAA), college aged
individuals, nearly 40 million, are experiencing depression and anxiety. The National Institute of
Health(2014) has also identified college students as an at-risk group for the development of
depressive symptoms and diagnosable depression(Pedrelli., Nyer., & Zulauf). Recognizing this
issue and applying interventions are important because 75 percent of lifetime cases of mental
health conditions begin by age 22(ADAA). College students are burdened with stress ranging
from a multitude of forces including academic pressures, family responsibilities, job balance,
social pressures, food insecurity, homelessness, and homesickness(Pedrelli., Nyer., & Zulauf,
2014). Modern medicine treats these mental health issues without keeping in mind the source of
these issues and often leads to the prevalence of psychiatric and substance use problems in
college students. The lack of comprehensive care for depression and anxiety often impedes on
the college students’ academic success along with other consequences for themselves, their
family and friends.
Depression is often characterized by symptoms of feeling sad, anxious, empty, hopeless,
helpless, worthless, guilty, or generally pessimistic, feeling more irritable than normal, and
apathetic to their lives(mentalhealthnet.org).There are 6 different types of depressive disorders:
seasonal affective disorder, bipolar disorder, persistent depressive disorder, major depression,
PMDD, and perinatal depression.While there are many similarities among them, each depressive
disorder has its own unique set of symptoms.
Anxiety disorders are the most prevalent psychiatric problems among college students,
with approximately 11.9 % of college students suffering from an anxiety disorder(Pedrelli.,
Nyer., & Zulauf, 2014). Anxiety disorders differ from everyday anxiety because it can interfere
with daily activities and often involves feeling extremely worried or afraid most of the time.
Anxiety disorders include generalized anxiety disorder, panic attacks, post-traumatic stress
disorder, and obsessive-compulsive disorder.
Within mainstream medicine, the healthcare system is less aware and oftentimes neglects
how diet plays a critical role in mental health. This factor is often unaccepted among the range of
biological, social and economic factors. Improving the coping mechanisms for these stressors
has been neglected. To address depression, the NIH recommends talk therapy and medication as
interventions(Pedrelli., Nyer., & Zulauf, 2014). Though, new research is signifying the
connection between dietary choices and mental health illnesses particularly with nutritional
deficiencies. In fact, nutrition can affect mental health in terms of development or exacerbation
of mental health symptoms. Depression and anxiety can also affect eating habits and lead to
under or over nutrition.

Research Discussion:
There is a link between poor mental health and under or overnutrition. Overnutrition is
attributed to the reliance on snacks and convenience foods, lack of regular exercise, apathy and
reduced motivation to address weight gain, antidepressants, and a diet that is higher in fat and
lower in fiber. Overnutrition involves an increased appetite and food cravings which often results
in weight gain. To maintain a healthy weight and promote a healthy mind, the Academy of
Nutrition and Dietetics (AND) recommend planning 3 moderately portioned regular meals and
snacks(Wallace, n.d.). AND also recognizes that in order for the brain to register fullness and
satiety, one needs to take at least 20 minutes to finish their meal. In addition to slowly and
mindfully eating, they advise reaching for low calorie and nutrient dense foods such as whole
grains and water-rich fruits and vegetables(Wallace, n.d.). Also, they state how through eating
mindfully, these patient can savor and enjoy their meal more. On the other hand, depression and
anxiety can result in a loss of appetite which may trigger undernutrition. There is concern for
under-eating because it can lead to rapid weight-loss and nutritional deficiencies. AND has
determined the importance of establishing a positive environment and making the meal appealing
by adding a variety of fruits and vegetables for color and adding different flavors and
textures(Wallace, n.d.). Additionally, eating small frequent snacks may benefit the patient
especially due to their poor appetite. Furthermore, eating in a social setting is encouraged
because it can promote eating and increase positive feelings(Wallace, n.d.).
Along with over or under-nutrition habits, carbohydrate choices also directly affect those
struggling depression and anxiety. Refined carbohydrates lack in fiber and nutrients which leads
to rapid increases in blood sugar. This swing in blood sugar not only causes insulin resistance in
the long-term, it also contributes to poor mood and anxiety attacks. Carbohydrate consumption
causes certain neurons to release serotonin, the “feel-good” hormone. People struggling with
depression and anxiety often crave carbohydrates and tend to overeat high refined carbohydrate
and high-fat processed foods to feel these short-lived positive effects. Overeating these foods
produces a drug-like effect in the brain and eventually causes weight gain and addiction. Not
only does it produce shift in weight, AND mentions how these episodes of low and high blood
sugar lead to depression(Wallace, n.d.). Therefore, they suggest whole-grains because they
contain fiber which produces a moderate and longer lasting positive effect on brain chemistry
compared to the refined counterpart(Wallace, n.d.). High fruit and vegetable consumption are
also recommended carbohydrate sources because of their fiber, micronutrient, and antioxidant
content.
The research article “Intake of Raw Fruits and Vegetables Is Associated With Better
Mental Health Than Intake of Processed Fruits and Vegetables” (2018) discussed how young
adults have high vulnerability to suffering from mental illness and how fruit and vegetable
consumption can help. Antioxidants such as vitamin C and carotenoids are said to play a criticial
role in reducing oxidative damage which affects certain forms of depression. Additionally, the
water-soluble vitamins (vitamin C, and B vitamins), and certain minerals (calcium, magnesium,
and zinc) found in fruits and vegetables are important for optimal cognitive and emotional
functioning. According to the CDC, only 1 in 10 young adults are consuming the recommended
amount of fruits and vegetables. Fruits and vegetables in their different form:raw, cooked, and
canned affect the mental health of the subjects with different amounts of improvement(Brookie,
Best, and Connor, 2018). They measured the effects comparing the depressive symptoms, mood,
and flourishment which is defined as feelings of meaning, purpose, and fulfillment in
life(Brookie, Best, and Connor, 2018). Interestingly, high raw fruits and vegetables consistently
showed the most significant association with positive mental health. For example, raw vegetables
including carrots, dark leafy greens (kale, spinach), lettuce, cucumber, red onion, cabbage,
celery, tomato, and mushrooms marked positive effects on mood(Brookie, Best, and Connor,
2018). In terms of processed vegetables, pumpkin, mixed frozen vegetables, potatoes, sweet
potatoes, broccoli, and eggplant were also strongly connected to positive mood, and several of
these were also related to flourishing(Brookie, Best, and Connor, 2018). In terms of fruit, raw
bananas and apples were the strongest predictors of good mental health alongside other raw fruits
such as grapefruit, berries, kiwifruit, peaches, apricots, pear, frozen berries, and grapes that were
associated with positive mood and flourishing. Although this study shed light on raw fruits and
vegetables with the strongest impact on mental health, they mentioned how it can be variant on
the particular fruit and vegetable and nutrient(Brookie, Best, and Connor, 2018). This study
suggests raw fruits and vegetables provide more antioxidants and micronutrients, however, fat-
soluble vitamins and minerals will not be affected by cooking. Remarkably, they also found how
as servings of fruits and vegetables increased to 6.5, the subject’s rating of their mental health
improved and was comparable to the feelings of being unemployed to employed(Brookie, Best,
and Connor, 2018). Due to the impressive effect of produce consumption and the fact that this
population bears the lowest consumption, these results reaffirm young adults as an important
population to target for mental health nutrition intervention.
In addition to increasing fruit and vegetable consumption, the brain-gut axis research
indicates the importance of digestive health and proteins in improving mental health. The “Gut
microbiota, metabolism and psychopathology: A critical review and novel perspectives” article
noted how psychiatric health and the gut microbiome are closely connected(Groen, et al.,
2017).When the fecal transplant from rats exhibiting depression and anxiety were transferred to
germ free rats, soon these rats also showed depressive symptoms and anxious behaviors(Groen,
et al., 2017). This study indicates how the psychiatric pathological disorders can be caused by the
bacteria present in the gastrointestinal tract.The depressed rat also showed an increased
kynurenine/tryptophan ratio in blood which means lower tryptophan which also alters serotonin
levels(Groen, et al., 2017). The health of the microbiome is important because 90% of serotonin
is produced in the gut. Along with tryptophan, amino acids including tyrosine and glutamine
produce the neurotransmitters that contribute to a better mood(Wallace, n.d.). Eating a variety of
protein sources including fish, poultry, eggs, beef, pork, and legumes ensures not only getting
enough iron and B vitamins, but also getting the different amino acids necessary for
neurotransmitter production.
While managing the gut microbiome and eating sufficient amounts of different protein
sources is necessary, balancing the omega 3 to 6 fatty acids is also important for mental health.
According to “Adolescent Behavior and Dopamine Availability Are Uniquely Sensitive to
Dietary Omega-3 Fatty Acid Deficiency”, a deficiency in omega 3 fatty acids and low levels of
circulating cholesterol can affect the development of depression as omega 3’s ensure brain
development and maintaining optimal brain function(Bondi, 2014) . Omega 3 fats have
demonstrated mood stabilizing effects on depressed individuals and it may be due to its anti-
inflammatory properties. Therefore, Mental Health America recommends consuming high
omega 3 fats such as oily fish (salmon, trout, mackerel, anchovies and sardines) which contain
high amounts of both EPA and DHEA. Although low in DHEA, omega-3s can also be found in
walnuts, flax (or flaxseed oil), olive oil, fresh basil and dark green leafy vegetables. To also
stabilize blood sugars and prevent mood disturbances, AND recommends regular, moderate
amounts of healthy fats daily such as avocado, nuts, and olive oil(Wallace, n.d.).
In addition to increasing a healthy ratio of omega 3 to 6, it is important to recognize
vitamins and mineral deficiencies that lead to depressive and anxiety symptoms. Due to these
vitamins and minerals influence in neurotransmitter production, ensuring enough vitamins B1,
B6, B12, C, D, and folate, and minerals (copper, iron, magnesium, zinc) through real food is
recommended(Wallace, n.d.).Vitamins and minerals assist in chemical reactions that are
necessary for overall health including mental health. Vitamin B-12 and other B vitamins play a
pivotal role in producing brain chemicals that affect mood and other brain functions which
means insufficient sources may contribute to depression. Rates of depression are also higher in
people with Vitamin D deficiency compared to people who have adequate levels. Therefore, the
Mental Health America advises getting enough sunlight and food sources of vitamin D. Natural
sources of Vitamin D include fatty fish like salmon and tuna as well as fortified products such as
milk, orange juice and breakfast cereals. Commonly found in leafy green vegetables like spinach
and kale, fruits, nuts, beans and whole grains, an increased intake of folate is associated with a
lower risk of depression. Other minerals involved in possibly preventing the development of
depression include calcium, chromium, iodine, and selenium(Wallace, n.d.). AND also
recommends special consideration to these nutrients: vitamins B1, B2, B6, B12, and folate, as
well as minerals: phosphorus, zinc, magnesium, and iron(Wallace, n.d.). As these nutrients are
commonly insufficient in depressive patients’ diets, AND reinforces how important it is to get a
variety of protein sources to meet B vitamins, phosphorus, zinc, and iron needs. Additionally, a
variety of fresh fruits and vegetables and nuts and seeds help get sufficient sources of folate and
magnesium.
In addition to food, consuming sugary and caffeinated drinks are tied to anxiety and
depression. Not only do sugary drinks have empty calories and damage tooth enamel, they also
affect blood sugar and lead to mental disturbances in vulnerable populations. According to
Mental Health America, limiting caffeinated beverages can prevent panic attacks in people who
have anxiety disorders. Caffeine is a stimulant which can negatively impact those facing mental
illness, thus it is advised to drink tea instead which has a high antioxidant content that prevents
oxidative damage. Furthermore, drinking at least 8 glasses of water a day is necessary because
studies signify that even mild dehydration can cause fatigue, difficulty concentrating, and mood
changes(Wallace, n.d.).
The American Psychological Associate’s article called “Exercise Effect” has pointed to
how exercise can also help alleviate long-term depression and anxiety. The findings suggest that
physical exercise could help to ward off panic attacks(Weir, 2011). The regular workouts helped
those people prone to anxiety become less likely to panic because the exercise induced similar
fight or flight, so their fight-or-flight sensations lessen (Weir, 2011).In addition to warding off
anxiety symptoms, regular exercise helps depression as conclude from the series of randomized
controlled trials done by Blumenthall (Weir, 2011). The trials involved assigning sedentary
adults with major depressive disorder to one of four groups: supervised exercise, home-based
exercise, antidepressant therapy or a placebo pill. What resulted were patients in the exercise and
antidepressant groups having the higher rates of healing completely than did the patients on the
placebo (Weir, 2011). Therefore, they found exercise is generally comparable to antidepressants
for patients with major depressive disorder. Exercise can combat psychiatric symptoms by its
ability to reduce stress and release endorphins, the chemicals that have a naturally relaxing effect
on the body.
Recommendation:
As opposed to pharmaceutical treatment that involves adverse side effects, it is
recommended to include therapeutic lifestyle changes to address depression and anxiety.
Therapeutic Lifestyle Changes (TLC) should be included in every major medical treatment as
integrative care because it works and costs less than medication. TLCs include exercise, nutrition
and diet, time in nature, relationships, recreation, sleep and stress management, religious or
spiritual involvement and service to others(Walsh,2011). In addition to being effective and
involving no side effects, TLCs protect the brain from damage particularly regular exercise,
healthy diet, and meditation(Walsh, 2011). Along with a medical program that educates students
on the importance of TLCs, colleges should offer nutritional education and tests for nutrition
deficiencies or insufficiency before administering antidepressants to students. Many college
students need integrative services such as learning how to start a meditation practice or how to
incorporate fruits and vegetables on a tight budget. The Health Promotion and Wellness program
(HPW) on campus has used strategies to enhance TLC seeking and engagement among college
students. They have used free aromatherapy and tea and brought dogs to promote stress
reduction and self-care. Additionally, many students may not find fruits and vegetables
affordable on a tight budget unless they were aware of SF State’s Health Promotion and
Wellness program offering Cal-Fresh assistance or learned about the Food Pantry on campus.
HPW outreaches to students through tabling, social media, interviews, and fliers made by the
interns. In order to serve students, it is important that our school require these resources to be
visible on the syllabus, so food insecure students know where they can access healthy food. In
addition to finding healthy food, learning about cooking is also important skill that college
students need. Last semester, the HPW at SF State offered cooking classes featuring the fresh
produce from the Food Pantry. These classes give food insecure students the tools on how to
cook as well as how to reap the health benefits because it was led by Dietetic students. In
addition to education outside of the health center, dietitians in campus health centers should be
required to screen the patient experiencing mental health disturbances and give them the
nutrition education to reclaim their health. Many college students resort to medication which are
insufficient when the source of the issue may be a nutrition insufficiency or poor lifestyle coping
mechanisms. After a nutritional screening, physicians should also advise regular exercise for 30
minutes each day and a balanced diet before prescribing medications as the last resort.
Campus resources also should work together in supporting healthy lifestyle choices as
well and addressing the barriers. For instance, a college student may believe they have limited
time that prevents them from exercising. Thus, they need advisors, therapist, or coaches to point
to using the stairs, walking to class, and scheduling in physical activity(Campus Mind Work).
The depressed individual may have no motivation or interest in physical activity until they are
reminded of how it will improve their mood and find a more enjoyable regimen such as dance or
kickboxing. Having a counselor and therapists involved with the medical treatment can help
motivate the student to adopt healthier coping strategies and reduce their symptoms. For
instance, the therapist can encourage physical activity and communicate with the dietitian to
individualize the treatment. It is important for an interdisciplinary team to communicate on
approaches to successfully help the patient make Therapeutic Lifestyle Changes. The campus
health or counseling center may also organize support groups for students with depression,
anxiety or other disorders. For example, Active Minds, is a peer group organization US-wide
that forms a community among those who are facing or wanting to bring awareness mental
health disorders(Mental Health America).
 Reference List

Exercise. (n.d.). Retrieved from Campus Mind Work website:

http://campusmindworks.org/downloads/ exercise_barriers.pdf

What's Your Plan? College with a Mental Health Disorder. (n.d.). Retrieved from
http://www.mentalhealthamerica.net/whats-your-plan-college-mental-health-disorder

Bondi, C. (2014). Adolescent Behavior and Dopamine Availability Are Uniquely

Sensitive to Dietary Omega-3 Fatty Acid Deficiency. Biological Psychiatry, 75(1).
https://doi.org/10.1016/j.biopsych.2013.06.007

Brookie, K., Best, G., & Conner, T. (2018). Intake of Raw Fruits and Vegetables Is
Associated With Better Mental Health Than Intake of Processed Fruits and Vegetables. Frontiers
in Psychology. https://doi.org/10.3389/fpsyg.2018.00487

Pedrelli, P., Nyer, M., & Zulauf, C. (2014). College Students: Mental Health Problems
and Treatment Considerations. Acad Psychiatry. https://doi.org/10.1007/s40596-014-0205-9

Robin N. Groen, Nicolien C. de Clercq, Max Nieuwdorp, H. J. Rogier Hoenders & Albert
K. Groen (2017) Gut microbiota, metabolism and psychopathology: A critical review and novel
perspectives, Critical Reviews in Clinical Laboratory Sciences, DOI:
10.1080/10408363.2018.1463507

Wallace, R. (n.d.). Depression: BHN Nutrition Fact Sheet. Behavioral Health Nutrition
Academy of Nutrition and Dietetics.

Walsh, R. (2011). Lifestyle and Mental Health. American Psychologist.

https://doi.org/10.1037/ a0021769

Weir, K. (2011, December). The Exercise Effect. Retrieved from

http://www.apa.org/monitor/2011/12/Exercise.aspx