The 4R Approach: Nutritional Considerations for Perinatal Mood and Anxiety Disorders
The Gestational Journey summit speaker, Stephanie Greunke, MS, RD, CPT, WHE, shares her approach to looking at the nutritional considerations for perinatal mood and anxiety disorders...
Stephanie is a registered dietitian, so it’s not surprising that she considers food as medicine. She strongly believes that what you eat has a significant impact on your overall health. While most people look at the impact of food on physiological/physical health, such as weight and cardiovascular health, it is important not to forget about the important role that diet plays on psychological/mental health. In this article, Stephanie discusses nutritional considerations for perinatal mood and anxiety disorders (PMADs) using her 4R approach. While the content is geared towards addressing mom’s needs, these tips can also benefit partners, caregivers, and adoptive parents.
Today, many parents are struggling. PMADs are the most common complication of childbirth and are a leading cause of maternal morbidity and mortality. At least 1 in 7 mothers experience serious depression or anxiety during pregnancy or postpartum, 1-2 out of 1,000 have postpartum psychosis, and let’s not forget about the 1 in 10 fathers (and other partners) who also experience postpartum depression or anxiety. PMADs can begin any time during or after pregnancy, after a pregnancy loss or after an adoption.
A treatment plan will be specific to each woman, but a good starting place is an understanding of potential causes. She may need the support of medication, therapy, supplements, group counseling, or a mixture of these modalities. My 4R approach for modifying a mom's diet is an additional support for her mental health. The 4Rs are as follows: Reduce inflammation, regulate blood sugar, replenish nutrient stores, and repopulate the gut.
This is easier said than done when you’re working with a population that may struggle to get out of bed in the morning and has little to no appetite. The significant benefits of these dietary modifications have been well-documented, however, and to ignore them would be a disservice to postpartum mothers.
Inflammation is associated with the onset of major depressive disorder outside of the context of pregnancy and childbirth. Inflammation is also associated with pregnancy complications such as preeclampsia, preterm birth, and gestational diabetes, and it’s quite possible that inflammation may play a role in perinatal mood disorders. Inflammation from various sources, including refined sugar, stress, and chemical exposures, can cause inflammation in the brain, impacting the production of mood-boosting neurotransmitters, such as serotonin.
Taking a high-quality fish oil is a standard recommendation for treating mood disorders per the American Psychiatric Association. Consuming low-mercury, fatty-fish (such as wild-caught salmon and sardines) on a weekly basis, is also highly encouraged.
Fish oil is one of the most studied and effective dietary supplements for treating mental health conditions. It could be that the EPA/DHA in the fish oil reduces inflammatory cytokines (specifically TNF-x, IL-1, and IL-6) which are often elevated in those with major depression. By reducing systemic inflammation, we may be more able to treat or manage these mood disorders.
Secondly, consider adding turmeric to food, since it contains curcumin—a powerful anti-inflammatory agent that has shown potential antidepressant-like activities in animal studies. An easy way to consume turmeric is in a stir-fry with fresh/frozen vegetables, your protein of choice, and canned coconut milk. It can also be easily incorporated into soups and broths. If a women is not nursing (or gets approval from her provider while nursing*), she can consider a turmeric supplement that contain black pepper for enhanced absorption. The typical dose is about 500 mg twice a day.
Finally, focus on a consuming a whole foods diet and reducing sugar, processed foods, and refined grains. If moms are willing and able, I’ve seen great results using the Whole30 to reset their health, hormones, and relationship with food. After the 30 days, they systematically reintroduce potentially triggering foods to understand what works best for their mental and physical health. They then create a style of eating that works for them based on that valuable information.
*Turmeric is given an intermediate safety rating in terms of its breastfeeding risk per InfantRisk
Regulate blood sugar.
There’s an interesting directional relationship between diabetes and depression. Meaning, elevated blood sugar is associated with an increased risk of depression and depression is associated with an increased risk of diabetes. In fact, a study published in 2010 following more than 65,000 women for over a decade showed that women with diabetes were more likely to develop depression, even when other risk factors such as exercise and weight were accounted for. Another meta-analysis found that depression was associated with a 60% increased risk of type 2 diabetes.
There are a few reasons why blood sugar may play a role in the pathology of perinatal mood and anxiety disorders. We know that elevated blood sugar is an inflammatory state. Additionally, individuals with high blood sugar may be eating a diet high in processed grains and sugar, contributing to the body’s inflammatory burden. Excess dietary sugar, especially artificial sugar, can negatively impact gut and brain health and even lead to nutritional losses or deficiencies such as vitamin D, calcium, and magnesium which are extremely important for pregnant/postpartum mamas.
Start the day with a low-glycemic, antioxidant-rich, anti-inflammatory meal. This is a great way to set the stage for stable blood sugar and mood throughout the day. A breakfast consisting of a few eggs, smoked salmon, sautéed greens, and sliced avocado is much more satiating and nutrient-dense than a breakfast consisting of cereal, oatmeal, or processed grains and fruit.
The eggs, smoked salmon, sauteed greens and sliced avocado also contain nutrients that are often depleted during pregnancy, such as omega-3 fatty acids and selenium (in the salmon), B-vitamins, choline, and Vitamin D (in the eggs, especially the yolk), as well as trace minerals and antioxidants spread through that meal.
If breakfast is well-balanced, the next step is to look at lunch and dinner. Assess and determine what simple steps can be made to balance that meal by including protein, carbs, and fat from whole food sources. Something like a piece of fruit or a date bar is a whole food choice, but it may not work well for optimizing mood and blood sugar levels.
Shortcuts, like using frozen vegetables and pre-made condiments from Primal Kitchen, or The New Primal can make things easier. A lower-sugar smoothie or ordering pre-made meals from companies like True Fare and Territory Foods can also help busy moms or those that are struggling to eat or prepare meals.
Replenish nutrient stores.
It’s well-known that mothers need to increase their calories during pregnancy. A mom is said to be “eating for two” and is generally advised to increase her intake by about 340 calories per day in the second trimester and 450 calories per day in the third trimester. However, there’s an unfortunate disconnect between what’s needed during the third trimester and what’s needed postpartum.
If a mom is breastfeeding, she actually needs more calories postpartum than she did during pregnancy, about 500 extra calories/day while exclusively nursing. This accounts for an increase in metabolic rate and an increased need for certain vitamins, which are transported into her breastmilk.
Calorie and nutrient needs are also increased for tissue healing and repair, especially if mom is recovering from a surgical birth. Tissue/wound healing is an energy-demanding process, something that is often overlooked. Seeing at the cesarean rate in the US is over to 30% (as high as 37% in Florida), this needs to be considered to help women successfully recover from any nutrient losses or deficiencies as a result of pregnancy, childbirth, and nursing.
Focus on nutrient-dense foods, such as meat, fish, vegetables, fruits, and healthy fat at most meals. This will promote the intake of nutrients often depleted during pregnancy (as mentioned above). If mom is nursing, this will increase the concentration of certain nutrients in her diet that are passed into her breastmilk. If mom is deficient in certain nutrients, this affects the concentrations in her breastmilk. However, with a healthy diet rich in these nutrients and possibly supplementation (such as continuing on a prenatal vitamin and vitamin D), this can be corrected.
While grass-fed beef, wild-caught fish, pastured pork, and organic fruits and vegetables are ideal, this may not be feasible for everyone. Families can purchase high-quality protein when it’s on sale, purchase it in bulk at a discount (such as a cow-share), or choose to purchase only organic fruits and vegetables from the Dirty Dozen list, to reduce exposure to pesticides.
Repopulate the gut.
We used to think of the body as separate systems. We’re now beginning to understand that our body is deeply interconnected. The health of our gut can impact our mental health through the gut-brain axis and immune system health, since upward of 80% of our body’s immune system is in the gut.
Researchers refer to this as GALT (gut-associated lymphatic tissue). If food is not broken down properly or is foreign to the body (such as highly refined, processed foods), this can cause an inflammatory response, impacting how the entire body functions—including the brain. Additionally, bacteria in our gut can secrete chemicals and neurotransmitters, such as dopamine, serotonin, and GABA, which play a role in mood disorders like depression and anxiety.
Consume a diet rich in prebiotics and probiotics. Prebiotics include soluble fiber, resistant starch, and non-starch polysaccharides. Foods rich in prebiotics include garlic, onions, Jerusalem artichokes, leeks, asparagus, cooked and cooled potatoes, and green (unripe) bananas. Prebiotics feed your beneficial bacteria and have been associated with overall health and well-being.
Fermented foods such as sauerkraut and kombucha contain probiotics which also optimize the health of your gut.
Including a probiotic supplement with strains that have been specifically studied to reduce inflammation, such as L.paracasei, L.plantarum, and P. pentosaceus as well as strains that may have mood-enhancing properties, such as Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 can also be beneficial.
*Individuals with GI conditions, such as bacterial overgrowth, or those who need to follow a low-FODMAP diet will want to consider working with a functional medicine practitioner. These individuals may not tolerate large amounts of fibrous vegetables, fermented foods, and certain probiotics.
As healthcare providers, we need to strongly consider the importance of diet in managing mood disorders. It’s important to provide information to pregnant mamas and their families (since partners can also develop PMADs) so they understand potential implications for their lifestyle choices.
At the same time, we need to provide practical, realistic steps so that new parents feel empowered and supported with these behavioral changes. Change is never easy, but it’s exponentially more challenging when you’re navigating a mood disorder. With proper screening and treatment, however, these conditions are manageable and moms will get better. Postpartum Support International, a leading organization for perinatal mood disorders wisely states, “You are not alone. You are not to blame. With [proper] help you will be well.” We would do well to remind new parents of this truth.