Nutrition and Anxiety

Dec 01, 2019

Some people describe anxiety as unstoppable worry. Others feel an intense dread without a particular focus. People feel it in their bodies as chest tightness, weakness, nausea, dizziness or a pounding heart. Regardless of how an individual’s anxiety manifests itself, we unanimously agree it feels terrible.  And we want to feel better, so it's natural to wonder if and how nutrition can help reduce anxiety.

I say “we”, since along with millions of other people, I struggle with anxiety. Anxiety disorders are the most commonly diagnosed mental health issues today (1). Even in people without a pathological level of anxiety, anxious thoughts and feelings can interfere with a person’s social life, relationship with food and their bodies, professional and personal achievement. 

I’ve gathered resources on what nutritional factors are evidenced to impact anxiety, so that I can take the best care of myself possible, and help my clients do the same. Nutrition can be used as a first step to help yourself, or you can use it as an adjunct to treatments like medication or counselling. For other health and fitness professionals, I hope this summary provides an evidence based framework for guiding and empowering your clients.  

It’s very important to me that we all have access to evidence-supported advice for treating mental health, so we don’t lose crucial opportunities to help by doing “something we heard on the internet”. 

If you or someone you care about struggles with anxiety, see a mental health professional and if you want to add supportive nutrition, here’s what the evidence says.  (Note: I have chosen to include predominantly human studies, as rodent studies can only use proxies or so called “anxiety-like” behaviors. While animal studies are valuable, human evidence is more likely to be directly translatable for other humans.) 

Dietary Quality 

Higher scores for depression and anxiety are associated with a cluster of unhealthy lifestyle factors, including smoking, physical inactivity and poor diet (2). While many people are looking to add expensive “functional foods”, “superfoods” or dietary supplements to their daily habits in order to improve mental health, the strongest evidence for efficacy calls for addressing the foundations first and foremost: making better selections of food at daily meals and staying physically active.  

How is a “high quality diet” defined? What aspects can a consumer focus on?

Choosing mostly unprocessed foods is one concept that can guide behavior, and is applicable to international audiences while still accommodating regional preferences and tradition (3). A study of pregnant women found that consuming a typical Brazilian diet (predominantly rice, beans and tea) or a healthy diet was associated with lower anxiety scores compared to a processed diet (4). A traditional diet characterized by vegetables, fruit, meat, fish, and whole grains has been linked to better mental health outcomes than a “Western” diet high in processed or fried foods, refined grains, sugary products, and beer (5). Five consecutive nationwide studies of Canadians have correlated a lower fruit and vegetable intake with anxiety and other mental health disorders (6).

A 2017 analysis reports that diets which are more inflammatory (high in fat, sugar, processed and red meats, refined grains and alcohol) increase a person’s risk for anxiety by 60%, compared to diets with the lowest inflammatory scores (7). Consistent with this, Tayefi et al. report that subjects with severe anxiety also had high levels of circulating C reactive protein (hsCRP), a marker of inflammation (8). Another analysis found the increased risk of anxiety from consuming a diet high in processed and unhealthy foods was 27% and 29%, in Norwegian men and women, respectively (9). Consistent findings have been reported with Iranian adults (10).

One tool commonly used to assess diet quality is the Alternative Healthy Eating Index (AHEI 2010). Higher scores on AHEI-2010 were shown to be associated with lowered prevalence of anxiety in Iranian adults, with greatest effects in women and those older than 40 (11). Higher AHEI scores have also been shown to be associated with lower anxiety in military personnel (12). 

Randomized controlled interventions are necessary to determine causality, and more than a dozen studies have been conducted to see if improving diet quality could cause improvements in mental health. Of ten interventions which reported anxiety score outcomes, just 2 produced significant improvements due to the diet intervention. The remaining 8 trials did not achieve a statistically significant positive effect but none of the trials found the diet intervention to worsen symptoms. Common themes among these interventions were increasing intake of fruits, vegetables, fiber, and seafood (13). 

The bottom line: Evidence supports increasing fruits, vegetables, seafood, and whole grains eaten, as well as decreasing added sugars, fried foods, packaged foods, white flour and alcohol. Processed red meats (hot dogs, salami, bacon) should be minimized, but evidence is equivocal on unprocessed red meats such as fresh steak, pork, and ground beef, and the influence of poultry does not appear to be significant.

Dietary Diversity 

Measures of dietary diversity are lower in women with higher anxiety ratings (14 Poorrezaeian 2015). It is important to maintain a diverse diet and consume a variety of foods to obtain all the necessary nutrients, and if anxiety-driven food restrictions go unchecked, malnutrition and/or orthorexia can develop. 

It is possible that anxiety causes people to eat the same familiar foods on a regular basis, or limited diet diversity may encourages the development of anxiety. A less diverse diet leads to reduced bacterial diversity in the gut, increased intestinal permeability and chronic inflammation, all of which have been implicated in the development of mental health disorders (15). 

Food selection itself can be such a cause of anxiety, and restriction of food one way to cope with high anxiety levels. Today’s society encourages personal responsibility with regard to diet and health, yet nutrition messages inundating consumers are often inconsistent, misleading or incomplete. Focus groups have revealed that simply choosing what to eat is a significant source of confusion and anxiety (16).

Nutrition professionals can help our clients and patients by encouraging and demonstrating that all foods fit into a healthy diet, and choosing not to demonize or vilify food groups. Utilizing counseling strategies that are based on flexible dietary restraint as opposed to rigid restraint yields better long term outcomes in terms of mental health and weight loss.

The bottom line: Anxiety can lead to a reduction in diet diversity, and a limited diet can contribute to worsened anxiety. Professionals can assist by recommending and modeling inclusion of a wide variety of foods. It is not advisable to swear off certain items or forbid any food groups entirely. 

Impact of High Fat Diet 

High fat diets containing 45% and 58% kcal from fat cause anxiety-like symptoms and heightened sensitivity to stressors in rats (17,18). This effect is also seen in non human primates consuming a less extreme high fat diet with 37% of calories from fat (19). This increased anxiety-like behavior has been attributed to changes in how the brain produces, distributes, and responds to the neurotransmitter serotonin. In fact, there is some evidence indicating that antidepressant drugs which work via serotonin may have less efficacy when a high fat diet (45% calories from fat) is consumed (20). Dutheil et al. highlighted other brain changes that accompany high fat (60% of calories) diet-induced anxiety, including inflammation, disturbed glucose regulation, and elevated corticosterone (21). Fortunately, discontinuing the high fat diet reduced the anxiety and reversed many of the pathway disturbances.

It is important to note that the abundance of animal data on high fat diets and behavior is limited by the lack of a perfect model (mice don’t get generalized anxiety disorder, social anxiety or have panic attacks). These data may also be confounded by a calorie surplus or obesity, since the animals consuming high fat diets are virtually always also consuming a great deal more calories than the control group. However, animal studies have shown that consuming a diet with 60% calories from diet caused gut biome changes that led to neurologic dysfunction even in the absence of weight gain (22). 

High fat diets have also been linked to the development of anxiety in humans, especially in a hypercaloric state which produces obesity, inflammation and type 2 diabetes (23). High fat diets cause changes in gut bacteria which promote inflammation, increased gut lining permeability (“leaky gut”), and adversely affect mood and cognitive function (15).  When calories are limited, such as on a weight loss diet, it is possible that a higher level of fat in the diet may not have such negative consequences (24). However in free living humans, higher fat intakes correlate with higher calorie intakes and predispose towards gaining body weight, so a moderate fat diet would be preferable for mental health. 

Bottom line: Evidence supports moderating fat to help avoid negative impacts on brain function and mental health. High fat intake such as prescribed by ketogenic or low carbohydrate dieting may interfere with mental function and mood, increasing anxiety susceptibility.

Influence of Bodyweight

There is evidence that obesity favors the development of anxiety disorders (23). While on the surface this may appear as an unequivocal reason to lose excess weight, it presents a chicken-or-the-egg scenario, since it’s entirely possible that anxiety disorders cause weight gain, and not the other way around. Women with higher anxiety have been shown to consume more calories and fat, have a higher BMI and altered processing in the brain of high calorie food images (25). It’s unknown to what degree this altered brain processing may make weight loss harder. Would it be more feasible to reduce anxiety in order to lose weight, or would losing weight unlock the key to alleviating a patient’s anxiety? We simply don’t know. 

Does losing weight improve anxiety among overweight or obese men and women? It might, but it’s not a guarantee. In a review of seven interventional studies, three found that anxiety improved with weight loss and four interventions found no change in anxiety level (26)

The relationship between body weight and anxiety is more complex than “one causes the other”, in part because anxiety can make an individual eat more or less (27). Additionally, our society presents differential stressors on people of different body weights. An individual’s feelings of anxiety can be impacted by weight stigma and sexual harassment, variables which also may shift as they gain or lose weight. As such, a person who develops anxiety and gains weight as a result may encounter discrimination and trauma that further increase their mental health struggles in a feedforward direction.

Attachment anxiety in particular, characterized by feeling insecure about close relationships, is linked to binge eating (28). Anxiety has also been shown to be correlated with emotional eating, another known contributor to weight gain (29). 

Bottom line: For overweight or obese individuals, reducing body weight is more likely to improve anxiety than worsen it. For those experiencing weight related stigma, feelings of insecurity about relationships, binge eating or emotional eating, seeking treatment for anxiety may be a considerable help in not only feeling better, but attaining weight loss goals. 

Bisphenol A (BPA) Exposure 

Animal studies have demonstrated health and behavior problems as a result of exposure to bisphenol A, a compound found in many plastics. BPA increases anxiety-like behavior in mice, rats and prairie voles (30, 31, 32). 

BPA exposure causes most harm during development, so the risks are highest for in utero exposure to fetuses and consumption by young children. Health and behavior consequences may not be immediate but can appear later in life. Because giving this chemical to humans for the sake of experiments poses an obvious ethical dilemma, our evidence in humans is limited to observations. 

A study on young children found that higher levels of urinary BPA were associated with worsened anxiety, but only in boys (33). Another research team found differential behavior effects of prenatal BPA exposure on boys and girls, with boys showing worsened anxiety at 3-5 and 10-12 years of age. (34, 35). These findings are consistent with animal studies indicating that changes in neural development influenced by BPA can be lasting.

Removal of BPA has been a priority in the plastics industry, and its use has been outlawed in baby bottles by the FDA. However the replacement of BPA with other compounds has not necessarily been as successful as intended from a health standpoint. Bisphenol F, one such substitute, has been reported in a 2017 publication to cause worse anxiety-like behavior alterations in mice than BPA (36).   

Bottom line: As an adult, if BPA or other endocrine disruptors have contributed to your anxiety, sadly the majority of damage is likely already done. However you can reduce exposure to your offspring and impact future generations by using glass, stainless steel or ceramic products instead of plastic where possible.

Omega 3 Fatty Acids

Omega 3 fatty acid intake seems to play a role in anxiety, depression, and other mental health disorders (37).  Many studies have shown an association between low levels of serum omega 3 fats or elevated omega-6 fatty acids to worse depression symptoms. However, fewer human studies have been done looking at anxiety specifically, and evidence is mixed (38).

Observational study has revealed that people who consume the most DHA, one specific omega-3 fat, have been found to have up to a 50% reduced risk for anxiety disorders (39). The amount of serum DHA has also been shown to be inversely associated with anxiety disorders in pregnant women (40). Women with the lowest DHA levels were nearly twice as likely to be diagnosed with an anxiety disorder as women with higher levels. A study of older adults also found that higher levels of omega-3 fats in the blood were correlated with lower levels of depression and anxiety (41)

A randomized controlled trial conducted with medical students found that omega-3 supplementation (2.5 g/d, 2085 mg eicosapentaenoic acid and 348 mg docosahexaenoic acid for 12 weeks) reduced anxiety significantly compared to a control supplement with fatty acids reflective of the standard American diet. (42). Other reports however, have found that low blood levels of omega 3 fatty acids correlated with depression, but not with anxiety (43). In a clinical trial, consuming salmon 3 times a week was effective in reducing self-reported anxiety. (44)

The Bottom Line: Evidence supports consuming omega-3 rich oils from fish or supplements to help reduce anxiety. Three servings of fish a week or 2.5 grams of omega-3 oil from supplements is an effective dose. 

Trans Fat 

There is abundance of data indicating that animals consuming trans fat display increased anxiety-like behaviors across the lifespan (45, 46, 47). In humans, trans fatty acids and their food source hydrogenated oils have been shown to correlate with increased anxiety in both young and old people (41, 48).  A 2016 report linked trans fat intake with negative emotional affect, though they did not specifically assess anxiety (49). It was also found in the same study that adults with higher trans fat intakes struggled more with emotional regulation, having greater difficulty with emotional awareness, emotional clarity, and using strategies to manage their emotions (50). Even if these endpoints do not coincide exactly with anxiety, they are skills a person needs to recover or manage an anxiety disorder, and thus are pertinent considerations. 

The bottom line: Trans fat negatively impacts brain function. Evidence supports avoiding hydrogenated oils and the trans fats they contain as much as possible. Avoiding trans fat consumption may support a more positive baseline mood, as well as full capability to sense and respond strategically to the negative emotions which do arise. 

Vitamin D

A 2017 study of young females reported that low vitamin D levels were correlated with anxiety, and for each unit of vitamin D increase the risk of anxiety fell by 3.33% (48). In pregnant women, similar data has been reported, where lower levels of vitamin D were associated with higher scores on anxiety inventory tests, however these effects were not large enough to be statistically significant when other factors were statistically adjusted for (51). 

Circulating levels of vitamin D <25 nmol/l have been shown to correlate with anxiety and depression in fibromyalgia patients, as reported by Armstrong et al in the Journal of Clinical Rheumatology (52). 
In healthy young Australian adults, supplementing vitamin D at the level of 5000 IU daily did not change levels of anxiety or other markers of cognitive function, however the subjects had very adequate levels of Vitamin D prior to supplementation, on average 76 nmol/l (53).

The bottom line: Low levels of Vitamin D are associated with anxiety symptoms, but the directionality cannot be known until for controlled randomized trials are conducted. It is possible that anxiety influences Vitamin D levels by causing people spend less time outside and in the sun. If your Vitamin D level is below 30 nmol/l, taking a supplement may help improve your anxiety.

Tryptophan and other amino acids

Some evidence indicates that anxiety can be influenced by availability of the amino tryptophan (found in many foods) and the neurotransmitter serotonin, which is synthesized from tryptophan. Tryptophan depletion occurring naturally or experimentally can induce anxiety. In late pregnancy, blood levels of tryptophan fall until several days after birth, a phenomenon which is has been proposed to contribute to anxiety and depression at this time (54).

Experimental tryptophan depletion can be accomplished by giving volunteers a tryptophan free amino acid drink. Serum levels of tryptophan fall by 80% after consuming this drink compared to a placebo beverage. In studies of healthy young men and anxiety patients, this increased feeling of anxiousness and precipitated panic attacks when given a CO2 challenge (55, 56). Tryptophan depletion also reverses the effect of SSRI medications on social anxiety (57).

Tryptophan supplements (50 mg/kg/day) and a high carbohydrate diet have been shown to help reduce the negative moods associated with quitting smoking (58). However, a study among postpartum women found no effect of supplemental tryptophan (3g/d) on mood or anxiety (59). 5-hydroxytryptophan, a precursor to serotonin has been found no more effective as a treatment for anxiety when compared to placebo (60). 

Polymorphisms of genes impacting the serotonin synthesis pathway have been shown to impact prevalence of generalized anxiety disorder, (61) however there is insufficient evidence at this time that dietary intake of tryptophan influences anxiety in a clinically useful way. 

A supplement combining two other amino acids, L-lysine and L-arginine (2.64 grams of each) was shown in a 2007 publication to reduce anxiety in healthy humans (62). A second human study reported that a 10 day treatment with 3 grams L-lysine and 3 grams L-arginine modified subjects’ hormonal responses to a psychosocial stress test, elevating adrenocorticotropic hormone, cortisol, adrenaline and noradrenaline levels compared to placebo (63). However, it is unknown how these changes may affect a person’s experience of stressful or anxiety provoking situations.

The bottom line: More research is needed to clarify if amino acid supplements may play a role in reducing anxiety. Vegetarians and vegans should take care to obtain enough dietary protein to prevent amino acid deficiency.

Low Carbohydrate Diets / Rigid Diets

A single case report caught my eye in the literature because it’s one lots of people might identify with: going on a low carb crash diet before vacation can make anxiety symptoms much worse (64). In a 2006 paper published in the journal Psychosomatics, Ehrenrich documents the case of a female patient who had previously been successfully treated for panic attacks and anxiety symptoms, but whose symptoms re-emerged after beginning a low carb diet (the Atkins Diet) which restricted total carbohydrate to 20 grams per day. 

Attempting any restrictive diet can act as an anxiety trigger, and it may not be the reduction in carbohydrates per se that caused this individuals mental health to decline. Halyburton found no significant mood changes between subjects consuming 4% as carbohydrate; and subjects consuming a 46% of total energy as carbohydrate as part of a weight loss trial (65). Brinkworth et al. also reported no significant mood differences between two groups consuming energy matched diets containing 14% and 53% of energy from carbohydrate, respectively (24). 

The Bottom Line: Especially for people prone to anxiety, a flexible and sustained weight loss strategy is preferable over drastic or rigid regimens. A strict and inflexible diet approach creates anxiety around dietary lapses, whereas a flexible, non-perfectionistic approach is psychologically less problematic. 

Probiotics

A 2015 systematic review has concluded that there is limited evidence for probiotics to impact mood outcomes, so further clinical trials are needed (66). A 2017 systematic review identified 7 double blind, placebo controlled trials of probiotics which measured anxiety and or stress (67). Of these, five found positive results, though the strains of probiotic, dosing, and length of intervention all varied. Treatments which were reported to reduce anxiety measures included L. casei (24 billion CFU daily x 2 months), a combination of L. helveticus and B. longum (3 billion CFU daily x 30 days) and a higher self-reported intake of fermented foods (68, 69, 70). A 2017 paper reported that probiotic supplement Lactobacillus rhamnosus HN001 (6 billion CFU per day) decreased anxiety among women during pregnancy and the first 6 months post-partum (71).

The bottom line: The connection between the gut microbiota and mood is a rapidly evolving field of research. Consuming a wide variety of complex carbohydrates and fibers helps develop a varied gut biome and is recommended. It is too early to tell which supplement strains and doses may be helpful for anxiety, however evidence is mounting for bifidobacterium and lactobacillus strains. 

Micronutrients

Deficiency of magnesium, iron, or calcium produces anxiety-like behaviors in mice, and replenishing these minerals alleviates the behavioral symptoms (72). However, Jacka et al. report finding no relation between intake of magnesium, folate and zinc and anxiety in humans (73). A double-blind, randomized, controlled clinical trial conducted in 2014-2015 also found no effect of zinc or magnesium supplementation on anxiety symptoms in postpartum women (74). However, a 2013 meta-analysis of multivitamin/multimineral supplementation indicates that they may reduce anxiety and mild psychological symptoms in a general population (75). Because the formulations used have included many nutrients in varying levels, and because individual’s diets also vary, the optimal amounts of each nutrient which might be included in a multivitamin/multimineral supplement are unknown.

The bottom line: Do your best to eat an adequate diet and attain a full spectrum of vitamins and minerals from food. Multivitamins are an option to help ensure adequate intake of micronutrients when diet quality is suboptimal. 

Vegetarianism

Vegetarians show higher rates of depression and anxiety disorders, however it has been shown that the onset of these disorders typically precedes adoption of a vegetarian diet (76).

A vegan diet was tested in large workplace intervention and significantly improved anxiety, other markers of mental health, and productivity (77). While the study was randomized and controlled, because the subjects could not be blinded (they knew if they were in the vegan or control groups) it is possible these results are biased by the subjects’ perceptions. 

The bottom line: There is not enough evidence to either recommend or discourage vegetarianism for anxiety management. 

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