The SMILES trial, A randomised controlled trial of dietary improvement for adults with major depression was recently published BMC Medicine. It is the first randomized controlled trial to test whether dietary improvement can actually treat depression. Yes, we’re using dietary improvement and treat in the same sentence!
The objective was to determine if “structured dietary support, focusing on improving diet quality using a modified Mediterranean diet model” would have an impact on mood. The outcome is very exciting:
‘SMILES’ was a 12-week, parallel-group, single blind, randomised controlled trial of an adjunctive dietary intervention in the treatment of moderate to severe depression. The intervention consisted of seven individual nutritional consulting sessions delivered by a clinical dietician. The control condition comprised a social support protocol to the same visit schedule and length.
The results indicate that dietary improvement may provide an efficacious and accessible treatment strategy for the management of this highly prevalent mental disorder, the benefits of which could extend to the management of common co-morbidities.
These encouraging results were seen in participants who switched from a junk food diet to a real foods diet. Of the 67 who were enrolled in the study, the majority were using some form of therapy: psychotherapy and medications combined or psychotherapy only or medication only. There were 31 in the diet support group and 25 in the social support control group. Participants had to have been eating this diet in order to be accepted into the study:
a poor (low) intake of dietary fibre, lean proteins and fruit and vegetables, and a high intake of sweets, processed meats and salty snacks.
The dietary approach followed by participants in the study intervention group was the ‘ModiMedDiet’ which is based on the Australian Dietary guidelines and the Dietary Guidelines for Adults in Greece.
The primary focus was on increasing diet quality by supporting the consumption of the following 12 key food groups (recommended servings in brackets): whole grains (5–8 servings per day); vegetables (6 per day); fruit (3 per day), legumes (3–4 per week); low-fat and unsweetened dairy foods (2–3 per day); raw and unsalted nuts (1 per day); fish (at least 2 per week); lean red meats (3–4 per week), chicken (2–3 per week); eggs (up to 6 per week); and olive oil (3 tablespoons per day), whilst reducing intake of ‘extras’ foods, such as sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). Red or white wine consumption beyond 2 standard drinks per day and all other alcohol (e.g. spirits, beer) were included within the ‘extras’ food group. Individuals were advised to select red wine preferably and only drink with meals.
The dietary composition of the ModiMedDiet was as follows: protein 18% of total energy; fat 40%; carbohydrates 37%; alcohol 2%; fibre/other 3%.
Here are the reasons I’m excited about this research:
- It’s the first randomized controlled diet depression study and ONE THIRD of the dietary intervention group saw improvements in their depression symptoms. This was just diet alone and switching from processed/junk food to real food with no specific dietary restrictions!
- Participants also reported improvements in anxiety symptoms.
- The authors even addressed the cost factor, stating it was more affordable to eat this way ($112 per week vs $138 per week).
- The authors address the fact that the dietary intervention group was able to make these dietary changes “despite the fatigue and lack of motivation” that we so commonly see with depression.
- I’m optimistic about it paving the way for making dietary approaches part of the standard of treatment for mental health conditions. The paper suggests the addition of “clinical dieticians to multidisciplinary mental health teams.” I’d like to add that these dieticians, together with nutritionists and health coaches would need to be well versed in functional medicine approaches.
- According to an article on ABC, one participant continued the Mediterranean diet after finishing the study and is now doing a diploma in health science. How inspiring is this? When we get results like this we want to share them with everyone!
These are very encouraging results and we applaud the positive results of this SMILES study which are truly groundbreaking.
Let’s also be aware of where we are headed with future research and how we can improve on the trial diet. The researchers conclude with this comment about future research:
The scaling up of interventions and identification of the pathways that mediate the impact of dietary improvement on depressive illness are also key imperatives
Professor Jacka recently shared this paper on how personalized dietary interventions successfully lower post-meal glucose i.e. how certain foods can affect two people quite differently because of our unique gut bacteria. She said that she wants to do a similar personalized nutrition study for depression if they are successful in obtaining NHMRC funding.
Here are some questions I’ve been asked about this SMILES trial (and I’m sharing here in case you have similar questions):
- why did only one-third of the study intervention group see improvements?
- why was wheat and other grains included?
- why was low fat dairy and lean meats emphasized?
- why was there no mention of grass-fed meat, wild fish, healthy fats like butter and coconut oil, pastured eggs or chickens or quality organic fruits and vegetables?
The ideal dietary approach for anxiety, depression and any health condition is always one that high quality, is personalized and takes into account biochemical individuality. With the removal of gluten, grains and the inclusion of the other dietary changes mentioned above, plus addressing all nutritional imbalances I expect we will see more than one-third of the dietary group experiencing improvements in depression in future trials.
I truly appreciate the work of Professor Felice Jacka and her team and look forward to seeing more studies like the SMILES trial, using a personalized approach and quality foods that include grass-fed red meat and wild fish, plus pastured eggs or chickens, and healthy fats; and organic produce as a baseline.
And then future trials that also look at the impacts of these dietary changes on anxiety and depression: gluten and/or grain removal; removal of high histamine foods and high oxalate foods; a low FODMAPs diet; the specific carbohydrate diet/SCD; a Paleo diet and so on – all based on biochemical individuality. We know these diets works in clinical practice and now we just need the research to back this up. In part 2 of the blog, I share some incredibly inspiring diet-depression and diet-anxiety Paleo success stories.
In summary:
- a simple change like switching from junk to real food can have a major impact on your depression and anxiety – ONE THIRD of the dietary intervention group saw improvements in their depression symptoms and many also saw reduced anxiety. This is profound!
- you may need to make additional dietary changes (gluten-free, grain-free, low FODMAPs i.e. avoiding or adding certain foods based on your biochemical individuality) and always add healthy fats and focus on quality
- you may also need to address brain chemical imbalances with amino acids supplements, address gut health, adrenal issues, low zinc, low vitamin B6, low vitamin D etc. too
Are you encouraged by this research?
And have you made similar dietary changes to those done in the SMILES trial and seen a reduction in your anxiety and depression?
Have you removed gluten or grains and made additional dietary changes, and added supplements and seen even more benefits?
Note: to avoid confusion I’ve used the Australia spelling of “randomised” and “fibre” in the quoted sections and the US spelling “randomized” elsewhere in the blog.
Great news! So encouraging to see a study detailing the link between diet and depression. Who conducted the study? Was it conventional medicine people, or integrative medicine practitioners? I ask because if it was the former, that would be a positive step in changing the way mental illness is treated.
Anne
This study was done by Professor Felice Jacka and her team at Deakin University in Melbourne. Professor Jacka is Director of the Food and Mood Centre and founder and president of the International Society for Nutritional Psychiatry Research (ISNPR). More here http://foodandmoodcentre.com.au/about/meet-the-team/
This is one of many diet-depression and diet-anxiety papers published by Professor Jacka but is the first RCT on diet and depression. Here are links to some of her other papers:
– Nutritional medicine in modern psychiatry: position statement by ISNPR http://www.everywomanover29.com/blog/nutritional-medicine-in-modern-psychiatry-isnpr/
– The Anxiety Summit: The Research – Food to prevent and treat anxiety and depression? http://www.everywomanover29.com/blog/anxiety-summit-the-research-food-to-prevent-and-treat-anxiety-and-depression/
And yes all this work is contributing to how mental illness will be treated by mainstream medicine – which is so wonderful.
My book “The Antianxiety Food Solution” (on Amazon here http://amzn.to/2kptFWm) was published in 2011 so it’s exciting to see this scientific validation supporting my work and what is currently happening (and has been happening for many many years) in the functional medicine community for both anxiety and depression.
Very interesting. How do these results compare to drug results?
Brett
The results in the literature are mixed. The controversial 2010 paper:Antidepressant drug effects and depression severity: a patient-level meta-analysis states that “The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.” https://www.ncbi.nlm.nih.gov/pubmed/20051569
This Scientific American article is a useful summary: Antidepressants: Do They “Work” or Don’t They? – A new study finds little difference between pill and placebo https://www.scientificamerican.com/article/antidepressants-do-they-work-or-dont-they/
There is also the matter of side-effects, nutrient depletions and withdrawal effects. Dr Kelly Brogan writes about the withdrawal effects of SSRIs in this blog http://kellybroganmd.com/stop-madness-coming-psych-meds/
Thank you Trudy for all the study links. I plan on reading them tomorrow. I will say that , as a suffered of severe major depression, Paxil has worked dramatically. Though I still have some symptoms, my plan is to clean up my diet, then try to wean off. Your book has been life changing in that it gives me hope.
Anne
If you still have symptoms it really is worth looking at your diet and the other nutritional aspects covered in my book. I’m so glad that it gives you hope – AND it gives you practical steps to follow!
Trudy,
You Mention..” The ideal dietary approach for anxiety, depression and any health condition is always one that is personalized and takes into account biochemical individuality. ”
Where would I find someone like this to work with to come up with a personalized plan? (besides yourself, as I know you are booked up). What is the occupation name of someone like this?
Thanks in advance.
Amanda
A nutritionist or someone trained in functional medicine and nutrition
Thanks for sharing this wonderful study Trudy. I’m so glad to see this work from Dr. Jacka. As a nutritionist that trains other nutrition professionals on how to use bioindividual nutrition and therapeutic diets, it’s great to see this research on how diet can help. So while it might not have all of the dietary elements like gluten-free I have found to be important for anxiety, depression, autism and other neurological conditions, it shows how even simple changes go a long way to help. Further modifications will likely be even more helpful. And this study is a good place to start. I’m grateful for the work of researchers like this as they provide scientific evidence of what we see clinically. And as a person that trains both nutritionists and doctors (at http://bioindividualnutrition.com/training) this evidence is very important. I always try to include as much research like this as possible to help support practitioners making recommendations. Thanks to both of you for this.
Julie
Like you I love to see the research and I’m so thrilled about this study! Junk food to real food and 30% of the study participants report an improvement in depression!
We appreciate you for your valuable contribution to the field of autism nutrition! And now that you’ve taken this work on bioindividual nutrition and therapeutic diets (like gluten-free, low oxalate, low FODMAPs etc) beyond autism, we all get to benefit and so do our clients. As my community knows, I’m a HUGE fan of your work!
I’m also really hoping that feedback from you and other practitioners who see powerful clinical results from more advanced dietary interventions will help to influence future studies – so thanks for contributing to this discussion and sharing your perspectives.
Trudy, my doctor says that my adrenals are shot and I have a lot of toxicity, I eat a good diet, stay away from sugar, and most dairy. My vitamin c and d and zinc were a little low, but I found it strange that he gave me Tri-salts for magnesium, calcium, and potassium, along with a vitamin b shot even though all of these came back normal on my blood work. Can you make any sense of this? It doesn’t make sense to me. Thanks, Michele
Michele
I would ask your doctor why and get in the habit of always doing this (asking and keeping notes). These are electrolytes and good for the adrenals so that could be one reason
Changed my diet about 18months ago. Advised to go gluten & dairy free for acidity problems in stomach. Reflux. Have suddenly not reenable to cope with stress & having anxiety attacks at silly times & ALWAYS on the brink of tears. B/P also high & having to take medication – which I loathe. Was always able to cope with any situation- place & “make-do” & the equilibrium always maintained. Now ! Have no idea how to cope with a family happening & the fall out from it seems overwhelming & haunting me . Unable to sleep without assistance & not very happy with who & what I am right now
Donna
There can be many root causes of anxiety attacks, overwhelm, feeling tearful and being unable to sleep. It’s a matter of finding your root causes and addressing them. Going gluten and dairy free is a big first step for my clients. Next would be to address any nutritional deficiencies caused by leaky gut – possibly low iron and low zinc? And using the amino acids like GABA and tryptophan to ease the anxiety and help sleep while you figure it all out.
My book “The Antianxiety Food Solution” (more here https://www.everywomanover29.com/store/aafsbook.html) is a great place to start and this blog has a wealth of information too
Not sure where this comment belongs but I’ll put it here. Thank you!
Dear Trudy,
I just spent some time watching the Autoimmunity Master Class
and I felt driven to share a few thoughts with you after watching
it. I have watched numerous master classes, seminars etc. on the
computer( many thanks to you!) and have learned a great deal over
the years, but! Yep, there’s a ‘but’ unfortunately. There is one
thing so many of these doctors never stop to think about and I think
this happens because of the simple fact it is not part of their
living conditions. It is all nice and wonderful to learn what may be
causing your health problems and how you can help to lessen them and
hopefully even reverse them, BUT that requires extensive testing,
supplements, specialist visits etc and those cost MONEY!!!! Most of
what these doctors offer as a way to get back control of your
health, costs money! If one does not have money then they get left
out in the cold suffering with no way to help themselves. A great
many of the tests they speak about cannot be covered by insurance as
the insurance companies refuse to cover testing they deem ‘alternative’ and must
be done out of pocket. All fine and wonderful if your pockets have
money in them, but again, too bad for the person who has no money. I
end up turning off the class/seminar out of sheer frustration
because I’m sick to death of hearing about what I can do to get
better, but I can’t do any of it without money! Here is yet another
division within society and always between the haves and the have
nots! This has to end and hopefully soon. EVERYONE deserves the
right to be healthy or at least try to be! Somebody who has an open
mind in the medical field needs to help find ways to create health
without the high costs that exclude a huge portion of the
population. The unfairness within society I find repulsive and it
must end. We are all one so lets act like it!
Thanks Trudy for all you do in helping people. I just had to get
this thought out to you to ponder…
Sincerely,
Holly
Holly
Thanks for posing this question as it is very valid and something which is of great concern to me (and my colleagues) as more and more awareness is created around functional medicine and dietary approaches to healing.
In an ideal world all doctors would be doing this testing and it would be covered by medical insurance and/or part of government medicare (depending where you live). I do believe we are moving in this direction, slowly but surely. As more research is published, we can expect this to accelerate but I believe the biggest impact is grass-roots and people like you demanding this type of care from your doctor. Share research and resources and help to educate them, and find a new doctor if your current conventional doctor isn’t open. Also get involved in organizations that are moving this field forward – Alliance for Natural Health https://anh-usa.org/ and Environmental Working Group
https://www.ewg.org/ are two examples.
That being said there is SO much healing that can be achieved with simple changes like switching to real whole food (in this SMILES study the real food folks spent less on food), making sure to eat organic (buy organic, grow your own, be part of a community garden etc), eating to control blood sugar, getting off gluten/sugar/caffeine, eating an AIP diet (if that is applicable), getting rid of toxic home-cleaning products and cosmetics (disease risk is way higher with toxin exposure https://www.everywomanover29.com/blog/the-toxin-solution-an-interview-with-author-dr-joseph-pizzorno/), exercise, sleep, time in nature, looking at medication side-effects, and stress-reduction.
I have had 1000s of people tell me this is all they did to eliminate their anxiety and panic attacks – no testing and no supplements were needed. It may take longer and clearly there are many exceptions when more interventions are needed but I wanted to share this to convey it is possible.
Also do keep in mind that many of the experts on these summits and docuseries share a wealth of information via their blogs and podcasts too, and many have written books, all very affordable learning resources. Since you mentioned the Autoimmunity class, here are a few fabulous books I’ve reviewed:
Dr. Izabella Wentz – Hashimoto’s Protocol https://www.everywomanover29.com/blog/hashimotos-protocol-izabella-wentz/
Dr. Amy Myers – The Autoimmune Solution Cookbook https://www.everywomanover29.com/blog/the-autoimmune-solution-cookbook-by-amy-myers-md/
One other aspect is prioritizing what we spend on food and health – it’s gone down dramatically – the average American household spends around 10% of their income on food and yet in the early 1900s it was about 50%. I have had many folks say they can’t afford organic food and yet they purchase the latest iphone each year, go for pedicures each week, spend a lot on eating out and entertainment etc etc.
I’m going to reach out to colleagues to get additional feedback and will add this to my list of blog topics (and will share your concerns which I know are common.) I’m already in conversations with some of them re the cost of switching to organic and will add this testing/supps issue to the conversation.
I know it’s not a perfect answer, but I hope this helps a bit.