An article in Nature Medicine out in October 2022 sets out some of the developing understanding of using food as medicine[1]. Whilst for those practitioners already immersed in this strategic use it seems obvious, it is important to remember that many practitioners are not. In turn, many people and rather depressingly most government ministers are comfortable with the benign approach to food as energy/profit only.
The authors of this paper identify two important areas (in their opinion) that need urgent attention.
The first shift is an evolution in public health and policy from food security to nutrition security. One proposed definition of nutrition security, which is intended to be an additive to existing food security metrics, is consistent access, availability and affordability of foods and beverages that promote well-being and prevent and, if needed, treat disease[2].
A second, related shift is the incorporation of food-based nutrition strategies into healthcare systems and population health. To support this notion they have devised a food is medicine pyramid that emphasises prevention over treatment, and recognises the societal changes that have to compete with commercial offerings.
They elaborate further before setting out their twin concepts of nutrition security and Food is Medicine to provide a new foundation to accelerate the identification, prioritisation and integration of healthcare- and population-based interventions. These are required to be acted upon simultaneously to collectively improve access to, affordability and convenience of nourishing foods, while promoting health equity and reducing the health burdens and economic costs of diet-related diseases.
Mental Health Challenges
Of course even if access to healthy foods is easy, there is no guarantee they will be consumed, ironically it is the groups most in need of sustainable nourishment that tend to experience the greatest deficit in access and consumption. One increasingly vulnerable group are those people experiencing disruption to their mental wellbeing.
A recent report by the Joseph Rowntree Foundation highlighted the striking link between antidepressant use and deprivation: in 2021/22, more than twice as many patients were prescribed antidepressant drugs from practices in the most deprived areas in England than in the least deprived areas.
The loneliness, worry, grief and financial problems caused by Covid-19 and associated lockdowns appear to have damaged the mental health of people all over the world. In the first year of the pandemic, the global prevalence of anxiety and depression increased by 25 per cent, according to the World Health Organization. In the UK, young people are a particular concern: one in nine children aged 6 to 16 had a probable mental disorder in 2017; by 2021 that was one in six, according to NHS data.
The number of years of life lived in general good health differs by a substantial 18 years between the most and least deprived areas of England. Poor diets and obesity are established major risk factors for chronic cardiometabolic diseases and cancer, as well as severe COVID-19.
Current offerings from the stretched NHS applied psychopharmacotherapy and psychotherapy do not always bring the desired results in the treatment of mental disorders. As a result, other lifestyle oriented interventions are receiving increasing attention.
Nutrition and mental well-being
In recent years, there has been a surge in research on the effects of nutrition on mental status, which is an important aspect of the prevention of many mental disorders and, at the same time, may lead to a reduction in the proportion of people with mental disorders[3].
Although the level of calories consumed is increasing, it is not always providing the recommended values of micro- and macroelements that play a significant role in the proper functioning of the nervous system. B vitamins, zinc, and magnesium are three commonly deficient nutrients essential for mental health. Additionally, we consume less fibre- and nutrient-rich vegetables and cereal products than recommended.
Superimpose smoking, limited physical activity, and harmful alcohol consumption to the above dietary patterns, and you can quickly ascertain how the combination adversely affects health and development of mental disorders, including depression.
Apart from macro nutrient benefits selective food supplementation can also be beneficial in the treatment of psychiatric disorders. Among them, compounds such as S-adenosylmethionine, N-acetylcysteine, B vitamins including folic acid, and vitamin D. Also, omega-3 unsaturated fatty acids have a wide range of effects.
Omega 3s participate in synaptogenesis by influencing receptor degradation and synthesis. They have an anti-inflammatory effect and inhibit apoptosis. They affect cell membrane function, brain-derived neurotrophic factor (BDNF), which is involved in plasticity and neurodegenerative processes, and neurotransmitter reuptake.
Where Is The Nutrition Expertise
Recognising that most primary and secondary care clinicians have little training and little experience in the role that nutrition has in these and other condition, the BMJ published an article exploring how nutrition can be used for prevention[4]. Medical Schools will be able to use the described curriculum to incorporate nutrition into their training of future doctors and it can be used to inform on appropriate nutrition components for inclusion in the incoming medical licensing assessment.
However, the process of change will take years and must always be a challenge to apply in time limited environments where suitable opportunities for referral are limited.
Practitioners in the private field have a diverse range of educational backgrounds and whilst the integrity and expertise of many cannot be questioned there remains a large number of ill equipped practitioners offering dubious advice.
Obesity
One example in which there is a continuous range of claims and opportunities for error strewn advice is in the resolution or prevention of obesity.
A collection of scientists gathered at the Royal Society in Oct 22 to explore what they could agree on as the cause of the largest health threat facing mankind – global obesity and its related metabolic disruptions.
It seems that there was no consensus on the cause, but there was general agreement on what does not cause obesity.
No presenter argued that humans collectively lost willpower around the 1980s, when obesity rates took off, first in high-income countries, then in much of the rest of the world. Not a single scientist said our genes changed in that short time. Laziness, gluttony and sloth were not referred to as obesity’s helpers. In stark contrast to a prevailing societal view of obesity, which assumes people have full control over their body size, they did not blame individuals for their condition, the same way people are not blamed for suffering from undernutrition challenges, like stunting and wasting.
The researchers instead referred to obesity as a complex, chronic condition, and they were continuing their research to get to the bottom of why humans have, collectively, grown larger over the past half century. To that end, they shared a range of mechanisms that might explain the global obesity surge. And their theories, however diverse, made one thing obvious: As long as we treat obesity as a personal responsibility issue, its prevalence is unlikely to decline.
The varied and intersecting proposals immediately made clear that to successfully address the obesity crisis public policy has to change, in part as described above and that clinical care needs personalisation to ensure best outcomes. A single public health focussed strategy is unlikely to be sustainable or effective. Nutrition orientated professionals will always be required to help individuals navigate their many mechanistic possibilities.
Yet today instead of viewing obesity as a societal challenge, the individual choice bias dominates. It is steeped with misunderstanding and blame, and it is everywhere. People are simply told to eat more vegetables and exercise, the equivalent of tackling global warming by asking the public only to fly less or recycle.
Maybe we should re-think of this as an ‘obesities’ problem one that requires tailored support and clinical skills a rare combination but one that practitioners trained in functional medicine tend to use in every case.
References
[1] Mozaffarian, D., Blanck, H.M., Garfield, K.M. et al. A Food is Medicine approach to achieve nutrition security and improve health. Nat Med 28, 2238–2240 (2022).
[2] Mozaffarian D, Fleischhacker S, Andrés JR. Prioritizing Nutrition Security in the US. JAMA. 2021 Apr 27;325(16):1605-1606. doi: 10.1001/jama.2021.1915. PMID: 33792612.
[3] Grajek M, Krupa-Kotara K, Białek-Dratwa A, Sobczyk K, Grot M, Kowalski O, Staśkiewicz W. Nutrition and mental health: A review of current knowledge about the impact of diet on mental health. Front Nutr. 2022 Aug 22;9:943998.
[4] Jones G, Macaninch E, Mellor D, et al Putting nutrition education on the table: development of a curriculum to meet future doctors’ needs BMJ Nutrition, Prevention & Health 2022;e000510.
