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The Role of Diet in Sleep and Depression Makena Dyer, B.Sc. and Joannie Dobbs, PhD, CNS Human Nutrition, Food & Animal Sciences University of Hawai‘i at.

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Presentation on theme: "The Role of Diet in Sleep and Depression Makena Dyer, B.Sc. and Joannie Dobbs, PhD, CNS Human Nutrition, Food & Animal Sciences University of Hawai‘i at."— Presentation transcript:

1 The Role of Diet in Sleep and Depression Makena Dyer, B.Sc. and Joannie Dobbs, PhD, CNS Human Nutrition, Food & Animal Sciences University of Hawai‘i at Mānoa PCCHA Annual Conference, October 13-15, 2014, Seattle, WA

2 Learning Objectives Describe the relationship between sleep difficulty and depression Discuss research relating essential nutrients to sleep difficulty and depression Identify biomarkers linked to sleep difficulty and depression Identify appropriate/helpful questions regarding a patient’s diet that could indicate a role in sleep and depression issues

3 The Partnerships in Mental Health Dr Alan Hawk, M.D. – Psychiatrist for University Health Services at Mānoa triggered the initial exploration into the diet / mind relationship

4 The Partnerships in Mental Health Discussions with Dr. Hawk and Sue Myhre – nurse practitioner led to the development of a nutrition assessment tool. This tool incorporated many of the health conditions that are seen by multiple practitioners but could have a link to subclinical malnutrition.

5 The Role of Diet in Mental Health

6

7 Common Nutritional Issues in College Students Nutritional deficiencies – Iron – Potassium – Protein – Vitamin C Calorie restriction Shams et al. Singapore Med J. 2010; 51(2): Ouellette et al. J Am Coll Nutr. 2012; 31(5): Kolodinsky et al. J Am Diet Assoc. 2007; 107(8): Johnston et al. J Am Coll Health. 1998; 46(5): Butler et al. Am J Health Behav. 2004; 28(1): 24-32

8 DSM-5 Criteria for Insomnia “Dissatisfaction with sleep quantity or quality” – Difficulty falling asleep – Difficulty staying asleep – Waking up early Disrupts work and social functioning Occurs at least 3 nights per week for at least 3 months Occurs even if circumstances permit sleep Not related to other medical conditions or psychiatric drug use Adapted from The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition.: DSM-5 by American Psychiatric Association

9 Estimated Prevalence of Insomnia Other diagnostic criteria for insomnia – International Classification of Diseases-10 Overall prevalence of 10-40% in the U.S. Prevalence in younger adults (Kessler 2011) – 23.9% of adults – 24.2% of adults Mai and Buysse. Sleep Med Clin. 2008; 3(2): Unbehaun et al. Nat Sci Sleep. 2010; 2: Kessler et al. Sleep. 2011; 34(9): 1161–1171

10 Sleep Difficulty in College Students 38% of students had poor quality sleep (Lund et al. 2010) 9.5% of students had chronic insomnia (Taylor et al. 2013) Lund et al. J Adolesc Health. 2010; 46(2): Taylor et al. Behav Ther. 2013; 44(3):

11 DSM-5 Criteria for Major Depressive Disorder At least five of the following symptoms

12 DSM-5 Criteria for Major Depressive Disorder Occurs in the same two-week period Impairs work and social functioning Not related to other medical conditions or drug use Adapted from The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition.: DSM-5 by American Psychiatric Association

13 Estimated Prevalence and Incidence of Major Depressive Disorder Lifetime prevalence in the U.S.: 16.2% of adults (about 34 million) (Kessler 2003) – 34 million individuals is almost equal to entire population of Canada Major depressive episode in past year in young adults (SAMHSA 2013) – 8.9% of adults (21.5 million) – 7.6% of adults (18.4 million) Kessler et al. JAMA. 2003; 289(23): Substance Abuse and Mental Health Services Administration, NSDUH Series H-47, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

14 Depression in College Students Healthy Minds Study (2007 and 2009) – 17% had signs of depression – 9% had major depressive disorder – 8.5% had taken antidepressants in past year Lifetime prevalence of suicidal thoughts in college students (Drum et al. 2009) – 18% of undergraduates – 15% of graduate students Hunt and Eisenberg. J Adolesc Health. 2010; 46(1): 3-10 Eisenberg et al. J Nerv Ment Dis. 2011; 199: Drum et al. Prof Psychol-Res Pr. 2009; 40(3):

15 Medical spending – Prescription medication $1.6 billion nationwide for prescription sleep aids in 2011 (Willyard 2012) $2.3 billion in Medicaid spending for antidepressants in 2004 (Chen et al. 2008) – Over-the-counter drugs $326 million for OTC sleep aids in 1995 (Martin 2004) Costs of Sleep Difficulty and Depression Willyard. Nat Med. 2012; 18(7): 996 Chen et al. Res Social Adm Pharm. 2008; 4(3): Martin et al. Sleep Med Rev. 2004; 8(1): 63-72

16 Costs of Sleep Difficulty and Depression Economic losses (lost productivity) – Up to $41 billion for insomnia (Martin 2004) – Up to $33 billion for depression (Wang 2003) Martin et al. Sleep Med Rev. 2004; 8(1): Wang et al. Int J Methods Psychiatr Res. 2003; 12(1): 22-33

17 Costs of Sleep Difficulty and/or Depression Increased risk of illnesses – Cardiovascular disease – Type 2 diabetes mellitus – Fibromyalgia – Headache – Hypothyroid Shankar et al. PLoS One. 2010; 5(11): e14189 Ariyo et al. Circulation. 2000; 102(15): Knol et al. Diabetologia. 2006; 49(5): Hakkarainen et al. J Epidemiol Community Health 2007; 61: 53-58

18 Relationship Between Sleep Difficulty and Depression Frequently observed together in patients Cause-and-effect relationship not yet determined – Which comes first? – Other causes? Nutt et al. Dialogues Clin Neurosci. 2008; 10(3): Wiebe et al. Nat Sci Sleep. 2012; 4: 63-71

19 Is There a Connection to Nutrition?

20 Role of Nutrients in Sleep and Mood Nutrients are involved in biochemical processes Important process for sleep and mood is neurotransmitter synthesis

21 Neurotransmitters

22 Neurotransmitter Synthesis Hare 2004 Amino acid Cofactor: Vitamin B-6 Kuhn et al. J Biol Chem. 1980; 255(9): Stahl. J Clin Psychiatry. 2008; 69(9): Elsworth and Roth. Exp Neurol. 1997; 144(1): 1-9 Hare and Loer. BMC Evol Biol. 2004; 4:24 Cofactors: BH4 (requires folate) and iron

23 Hickman 1999 Neurotransmitter Synthesis Acetyl CoA from pantothenic acid Methyl group from SAM (requires folate and Vitamin B-12) Hickman et al. Mol Cell. 1999; 3: Axelrod and Weissbach. Science. 1960; 131(3409): 1312 Bottiglieri. Prog Neuropsychopharmacol Biol Psychiatry. 2005; 29(7):

24 Neurotransmitter Synthesis Amino acid Hare 2004 Cofactors: BH4 (requires folate) and iron Cofactor: Vitamin B-6 Cotter and O’Keeffe. Ther Clin Risk Manag. 2006; 2(4): Stahl. J Clin Psychiatry. 2008; 69(9): Elsworth and Roth. Exp Neurol. 1997; 144(1): 1-9 Hare and Loer. BMC Evol Biol. 2004; 4:24

25 Neurotransmitter Synthesis Cofactor: Copper Vitamin C keeps copper in reduced state Methyl group from SAM (requires folate and Vitamin B-12) Goridis 2002 Goridis and Rohrer. Nat Rev Neurosci. 2002; 3(7): Levine et al. J Biol Chem. 1985; 260(24):

26 Other Issues with Neurotransmitters and Diet Bioavailability is also important – Role of carbohydrates Benton and Donohoe. Public Health Nutr. 1999; 2(3A): ↑ Carbohydrate intake ↑ Insulin release ↑ Tryptophan available relative to other amino acids ↑ Tryptophan delivery to the brain via albumin transport proteins

27 Nutrients with Special Importance for Neurotransmitters MACRO-NUTRIENTS Protein Carbohydrate Fat (omega-3 & 6 fatty acids) Water Micro-Nutrients Vitamins Water Soluble B1, B2, Niacin, B6, Folate, B12 Biotin, Pantothenate, C, Choline Fat Soluble A, D, E, K Minerals (Ash) Major Minerals Calcium, Chloride Magnesium, Phosphorus Potassium, Sodium, Sulfur Trace Minerals Chromium, Cobalt, Copper, Fluoride, Iron, Iodine, Manganese, Molybdenum Selenium, Zinc Other Trace Minerals Appear to be essential: Arsenic, Boron, Nickel, Silicon Possibly essential: Cadmium, Lead, Lithium, Aluminium, Bromine, Rubidium, Vanadium Other Food Substances Caffeine Cholesterol Dietary Fiber Other Phytochemicals

28 Summary of Nutrients with Special Importance to Sleep and Depression MACRO-NUTRIENTS Protein Carbohydrate Fat (omega-3 & 6 fatty acids) Water Micro-Nutrients Vitamins Water Soluble B1, B2, Niacin, B6, Folate, B12 Biotin, Pantothenate, C, Choline Fat Soluble A, D, E, K Minerals (Ash) Major Minerals Calcium, Chloride Magnesium, Phosphorus Potassium, Sodium, Sulfur Trace Minerals Chromium, Cobalt, Copper, Fluoride, Iron, Iodine, Manganese, Molybdenum Selenium, Zinc Other Trace Minerals Appear to be essential: Arsenic, Boron, Nickel, Silicon Possibly essential: Cadmium, Lead, Lithium, Aluminium, Bromine, Rubidium, Vanadium Other Food Substances Caffeine Cholesterol Dietary Fiber Other Phytochemicals

29 We Wanted to See if the Relationship Between Depression and Insomnia Could be Seen in the NHANES Studies

30 National Health and Nutrition Examination Survey (NHANES) Nationwide study on health and nutrition 5,000 individuals each year from 15 counties Two-year studies since 1999

31 NHANES Mobile Exam Center

32 NHANES Datasets Adapted from wwwn.cdc.gov NHANES – Demographics Data – Dietary Data – Examination Data – Laboratory Data – Questionnaire Data

33 Insomnia and Depression Research Objectives Compare nutritional statuses – Individuals with both insomnia and depression – Individuals with neither insomnia nor depression Determine what nutrients and biomarkers are most important to understanding these conditions

34 Study Sample NHANES and datasets – Complete sleep and depression data Ages years n=2,744 – 1,307 females – 1,437 males

35 Dietary Data 24-hour diet recall – Multiple pass method – USDA’s Food and Nutrient Database

36 Questionnaire Data: Prescription Medications Antidepressant drug use in past month 26/mentalhealth.medicalresearch oral/sertraline-oral/details#images/

37 Questionnaire Data: Insomnia Sleep Disorders questionnaire – Length of sleep – Sleep disorder diagnosis – Frequency of sleep complaints – Severity of daytime impairment

38 Insomnia Criteria for This Research Based on DSM criteria Frequency of “Often” (5-15 times) or “Almost always” (16-30 times) in past month for one or more of the following: Trouble falling asleep Waking up during night Waking up too early in the morning Vozoris. J Hypertens. 2013; 31(4):

39 Depression Criteria for This Research Patient Health Questionnaire-9 (PHQ-9) – Based on DSM criteria Depression = PHQ-9 ≥ 10 – Sensitivity of 88% in detecting depression (Kroenke 2001) Kroenke et al. J Gen Intern Med. 2001; 16(9):

40 Questionnaire Data: Depression

41 Data Analysis JMP Pro 11 – Data mining software beckerinfo.net

42 NHANES Data in JMP

43 Females Males

44 What else did we find about Insomnia and Depression? Females are not like males – Greater prevalence in females than males May persist even with antidepressant use For females, antidepressant use with persistent symptoms is associated with lower intakes of certain nutrients

45 TOTAL FEMALES No Symptoms Insomnia only Depression only Insomnia and Depression (n= 1307) %66.6%24.4%4.1%4.8% Antidepressant drug use No96.2%34.3%6.0%6.1% Yes3.8%2.3%0.2%1.1% Insomnia and Depression in Females

46 TOTAL MALE No SymptomsInsomnia only Depression only Insomnia and Depression (n = 1437) %76.7%18.2%2.2%2.9% Antidepressant drug use No98.3%23.3%2.9%3.5% Yes1.7%0.5%0.0%0.2% Insomnia and Depression in Males

47 Body Wt., BMI, Symptoms and Antidepressant Use in Female Subjects

48 The following Contour Graphs present proportional representations of data density – regardless of the total n

49 The following Contour Graph shows that the group with depression and insomnia and taking anti- depressants consumed less calories as a percent of their sedentary energy needs.

50 Relationship of Energy Intake to Insomnia and Depression Antidepressant Drug Use? No Yes n=33 n=837n=52n=102 outliers excluded

51 The following Contour Graph shows that the depression and insomnia group for all ethnicities was abnormal compared to the other groups.

52 Relationship of Energy Intake (by Ethnicity) to Insomnia and Depression Antidepressant Drug Use? No Yes Mexican- American Non-Hispanic Black Other Hispanic Other Race Non-Hispanic White

53 The following Protein Contour graph shows a similar profile to inadequate caloric intake. Most depressed females did not consume protein at the 0.8 grams protein/Kg B.Wt RDA level nor met the 1.6 grams associated with a lower BMI

54 Relationship of Insomnia and Depression to Protein Intake n=33n=10 n=52 n=828 Antidepressant Drug Use? No Yes 11 outliers excluded RDA for Protein = 0.8 gm/kg body weight Recommended Protein Intake for Some Individuals = 1.6 gm/kg body weight

55 Foods That Provide Protein Animal products – Meats – Fish – Cheese Beans* Nuts* *Incomplete protein (missing essential amino acids); lower digestibility and higher calories

56 Average Protein per Typical Food Serving Food Sources NLEA Serving Size (g) NLEA Volume per Serving Energy (kcal) Protein (g) Kcal/ g protein Fish / Chicken / Beef 85~ 3 oz. ckd1708 2% Cottage Cheese 110~ 0.5 oz. cup1008 Cheese301 thin slice11016 Legumes / Beans 90 ~ 0.5 oz. cup Beans - Processed 130~ 0.5 oz. cup15020 Grains cup16032 Nuts30~ 3.5 Tbsp

57 The following Contour Graph shows that the depression and insomnia group for all ethnicities was abnormal compared to the other groups.

58 Relationship of Magnesium Intake to Insomnia and Depression Antidepressant Drug Use? No Yes n=52n=10n=32n=836 4 outliers excluded RDA for Magnesium = 400 mg

59 Foods That Provide Magnesium Nuts Beans Spinach

60 The following DHA Contour Graph shows that the depression and insomnia group on an average consumes less DHA compared to the other groups.

61 Relationship of DHA Intake Insomnia and Depression Antidepressant Drug Use? No Yes n=10 n=33n=51 n= outliers excluded

62 Foods That Provide DHA

63 Summary of Nutrients with Special Importance to Sleep and Depression MACRO-NUTRIENTS Protein Carbohydrate Fat (omega-3 & 6 fatty acids) Water Micro-Nutrients Vitamins Water Soluble B1, B2, Niacin, B6, Folate, B12 Biotin, Pantothenate, C, Choline Fat Soluble A, D, E, K Minerals (Ash) Major Minerals Calcium, Chloride Magnesium, Phosphorus Potassium, Sodium, Sulfur Trace Minerals Chromium, Cobalt, Copper, Fluoride, Iron, Iodine, Manganese, Molybdenum Selenium, Zinc Other Trace Minerals Appear to be essential: Arsenic, Boron, Nickel, Silicon Possibly essential: Cadmium, Lead, Lithium, Aluminium, Bromine, Rubidium, Vanadium Other Food Substances Caffeine Cholesterol Dietary Fiber Other Phytochemicals

64 Questions to Ask in Clinic Are you restricting calories? – Concerned about weight? What drives your food choices? – Avoiding certain foods can lead to essential nutrient imbalances? Vegan diet “Clean” eating

65 Summary Insomnia and depression can be due to any of several factors Neurochemicals and antidepressants are just part of the picture Diet and nutrition may address factors not addressed by antidepressants

66 Acknowledgement This work is supported in part by USDA Smith Lever Funding for Project 289H.

67 Questions?

68 References American Psychiatric Association 2013 DSM-5 The Diagnostic and Statistical Manual for Mental Disorders, Ariyo et al. Circulation. 2000; 102(15): Axelrod and Weissbach. Science. 1960; 131(3409): 1312 Benton and Donohoe. Public Health Nutr. 1999; 2(3A): Bottiglieri. Prog Neuropsychopharmacol Biol Psychiatry. 2005; 29(7): Butler et al. Am J Health Behav. 2004; 28(1): Chen et al. Res Social Adm Pharm. 2008; 4(3): Cotter and O’Keeffe. Ther Clin Risk Manag. 2006; 2(4): Drum et al. Prof Psychol-Res Pr. 2009; 40(3): Eisenberg et al. J Nerv Ment Dis. 2011; 199: Elsworth and Roth. Exp Neurol. 1997; 144(1): 1-9 Goridis and Rohrer. Nat Rev Neurosci. 2002; 3(7): Hakkarainen et al. J Epidemiol Community Health 2007; 61: Hare and Loer. BMC Evol Biol. 2004; 4:24 Hickman et al. Mol Cell. 1999; 3: Hunt and Eisenberg. J Adolesc Health. 2010; 46(1): 3-10 Johnston et al. J Am Coll Health. 1998; 46(5): Kessler et al. JAMA. 2003; 289(23): Kessler et al. Sleep. 2011; 34(9): 1161–1171

69 References (continued) Knol et al. Diabetologia. 2006; 49(5): Kolodinsky et al. J Am Diet Assoc. 2007; 107(8): Kuhn et al. J Biol Chem. 1980; 255(9): Levine et al. J Biol Chem. 1985; 260(24): Lund et al. J Adolesc Health. 2010; 46(2): Mai and Buysse. Sleep Med Clin. 2008; 3(2): Martin et al. Sleep Med Rev. 2004; 8(1): Nutt et al. Dialogues Clin Neurosci. 2008; 10(3): Ouellette et al. J Am Coll Nutr. 2012; 31(5): Shams et al. Singapore Med J. 2010; 51(2): Shankar et al. PLoS One. 2010; 5(11): e14189 Stahl. J Clin Psychiatry. 2008; 69(9): Taylor et al. Behav Ther. 2013; 44(3): Unbehaun et al. Nat Sci Sleep. 2010; 2: Vozoris. J Hypertens. 2013; 31(4): Wang et al. Int J Methods Psychiatr Res. 2003; 12(1): Wiebe et al. Nat Sci Sleep. 2012; 4: Willyard. Nat Med. 2012; 18(7): 996

70 Images Slide 17: [Venn diagram of neurotransmitters]. Retrieved September 11 th, 2014 from: Slide 25: [logo of NHANES]. Retrieved August 31 st, 2014 from: Slide 25: [logo of CDC]. Retrieved August 31st, 2014 from: Slide 26: [photograph of NHANES MEC]. Retrieved August 31 st, 2014 from: Slide 27: [screen capture of NHANES menu]. Retrieved September 13 th, 2014 from: Slide 30: [picture of Prozac pill]. Retrieved October 9 th, 2014 from: Slide 30: [picture of Zoloft pills]. Retrieved October 9 th, 2014 from: 8095/zoloft-oral/sertraline-oral/details#images/ Slide 34: [screen capture of PHQ-9 questions]. Retrieved September 13 th, 2014 from: Slide 37: [logo of JMP]. Retrieved September 14 th, 2014 from: genomics-training/ All other images are from journal articles, Microsoft Clip Art, or original work.


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