The Importance of Diet and Gut Health To The Treatment and Prevention of Mental Disorders

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From S.L. Dawson, S.R. Dash and F.N. Jacka, The Importance of Diet and Gut Health to the Treatment
and Prevention of Mental Disorders. In: J.F. Cryan and G. Clarke, editors, International Review of
Neurobiology, Vol. 131, Burlington: Academic Press, 2016, pp. 325-346.
ISBN: 978-0-12-803949-6
Copyright 2016 Elsevier Inc.
Academic Press
Author's personal copy

CHAPTER FIFTEEN
The Importance of Diet and Gut

Health to the Treatment and
Prevention of Mental Disorders
S.L. Dawson*,,1, S.R. Dash*,{,1, F.N. Jacka*,,,||,2
*Food and Mood Centre, IMPACT SRC, Deakin University, School of Medicine, Geelong, VIC, Australia
Early Life Epigenetics Group, Murdoch Childrens Research Institute (MCRI), Royal Childrens Hospital,
Parkville, VIC, Australia
{
Collaborative Research Centre for Mental Health, Carlton, VIC, Australia
Centre for Adolescent Health, Murdoch Childrens Research Institute (MCRI), Royal Childrens Hospital,
Parkville, VIC, Australia
Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia

jj
Black Dog Institute, Prince of Wales Hospital, Randwick, NSW, Australia
2
Corresponding author: e-mail address: felicejacka@gmail.com
Contents
1. Introduction
2. Diet and Mental Health Across the Lifespan
2.1 Early Life, Childhood and Adolescence
2.2 Diet and Mental Health in Adults and the Elderly
3. The Importance of Diet for Gut Health Across the Lifespan
3.1 The Influence of Diet on Early Life Microbiota
3.2 The Western Diet Has a Detrimental Influence on Adult Gut Health
3.3 Beneficial Influence of Plant-Based Diets on Adult Gut Health
4. Opportunities for Prevention and Treatment of Mental Health Disorders
4.1 Dietary Strategies for the Prevention of Mental Disorders: A Public Health
Perspective
4.2 Targeting Early Life Gut Microbiota
4.3 Dietary Targeting of Mothers for Reducing the Risk
of Mental Disorders in Children
4.4 Diet as a Treatment for Mental Health
5. Conclusion
References
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Abstract
The departure from traditional lifestyles and the rising disease burden of mental disorders are increasing global health concerns. Changes in diet around the world mean that
populations are now increasingly reliant on highly processed, poor quality foods, which
1
Joint first author.
International Review of Neurobiology, Volume 131

ISSN 0074-7742
http://dx.doi.org/10.1016/bs.irn.2016.08.009
2016 Elsevier Inc.

All rights reserved.
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have been linked to increased risk for mental disorder. Conversely, a nutrient-rich diet is
understood to be protective of mental health, and researchers are now aiming to understand the biological underpinnings of this relationship. The gut microbiota has been
proposed as a key mediator of this link, given its association with both diet and mental
health. Importantly, several critical windows of opportunity for prevention and intervention have been identified, particularly early life and adolescence; these are periods of
rapid development and transition that provide a foundation for future health. Strategies
that promote overall diet quality, high in fiber and nutrients, have been linked to
increased microbial diversity and gut health. Improving diet quality and subsequent
gut health may have benefits for individuals mental health, as well as the mental health
of future generations. Here we discuss specific, targeted dietary and gut focused strategies for the prevention and treatment of mental disorder.
1. INTRODUCTION
Mental disorders, specifically anxiety and depression, account for a
significant proportion of global disease burden (Whiteford et al., 2013). Lifestyle has changed dramatically through globalization and urbanization, and
the shift away from more traditional lifestyles has been linked to an increase
in mental disorders (Logan & Jacka, 2014). Diet has recently been shown to
be one of the leading risk factors for early mortality (Global Burden of
Disease Study Collaborators et al., 2015) and is a shared risk factor for both
physical and mental disorders ( Jacka, Sacks, Berk, & Allender, 2014). The
relationship between diet and mental disorders is evident across countries,
cultures, and age groups and there is emerging evidence highlighting some
of the relevant pathways for this relationship (Berk et al., 2013; Jacka,
Cherbuin, Anstey, Sachdev, & Butterworth, 2015). One pathway of particular interest relates to the gut and its resident microbiota, as the microbiome
is strongly affected by diet and also appears to influence multiple factors
related to the risk for mental disorders (Dash, Clarke, Berk, & Jacka,
2015). Given the modifiable nature of the diet and the microbiome, this
new knowledge base affords the potential for new prevention and treatment
strategies for mental health and has significant implications for public health
and clinical treatment.
2. DIET AND MENTAL HEALTH ACROSS THE LIFESPAN

While diet quality has long been understood as important to physical
health, recognition of its relevance to mental health has been slower to

Diet, The Gut, and Mental Health
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develop (Sarris et al., 2015). Early nutritional psychiatry research focused

largely on individual nutrients, such as omega-3s or folate, and their relationship with mental health. However, given the synergistic nature of nutrients
in food, the field has since moved toward a whole of diet approach that
better captures these complexities (Hu, 2002). Dietary patterns in both affluent and developing countries now consist primarily of high-energy, nutrient
poor foods, and have shifted away from more traditional diets of the past,
comprised of higher intakes of plant foods and quality proteins (Logan &
Jacka, 2014). Over the last decade, evidence has accumulated to support
the relationship between diet quality and mental health and these associations have been consistently observed in adults, adolescents, and children
across a multitude of different countries and cultures ( Jacka, Mykletun, &
Berk, 2012).
2.1 Early Life, Childhood and Adolescence

A robust evidence base suggests that diet is important to mental health across
the lifespan, although there are particular periods of rapid development or
transition that present critically important windows of opportunity. Diet
quality before and during pregnancy is important to the mental health of
the mother (Baskin, Hill, Jacka, ONeil, & Skouteris, 2015), but also has
implications for the future mental health ( Jacka, Ystrom, et al., 2013;
Pina-Camacho, Jensen, Gaysina, & Barker, 2015; Steenweg-de Graaff
et al., 2014) and cognition (Barker, Kirkham, Ng, & Jensen, 2013) of her
offspring. This suggests the potential to target the nutritional status of a
woman during pregnancy in order to positively influence future mental
health outcomes in children (ONeil et al., 2014).
As in other domains of health, childhood experiences are highly impactful on future health (Heim, Newport, Mletzko, Miller, & Nemeroff, 2008).
Unfortunately, many studies have shown that young people are eating well
below dietary recommendations; the most recent Nutrition Survey in
Australia found that less than 1% of children met the minimum recommendations for the five major food groups (Australian Bureau of Statistics (ABS),
2016), and similar trends are seen globally (Kontogianni et al., 2008; Larson,
Neumark-Sztainer, Hannan, & Story, 2007; Northstone & Emmett, 2005).
Young people are increasingly reliant on nutrient poor, high sugar foods
such as sweets, soft drink, snacks, and baked goods (Adair & Popkin,
2005). These dietary patterns have linked to obesity and noncommunicable
disease, but the extant evidence suggests that what children and adolescents

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are eating is critically important to both the brain and mental health as well.
Consuming a diet of high sugar and snack-like foods has been linked to
behavioral and emotional problems in children ( Jacka, Ystrom, et al., 2013;
Kohlboeck et al., 2012; Overby & Hoigaard, 2012) which have been linked
to mental disorder in adulthood (Becker, El-Faddagh, Schmidt, & Laucht,
2007; Copeland, Shanahan, Costello, & Angold, 2009).
By adolescence, young people have greater independence in food
choices and begin to establish dietary habits that will carry through to adulthood (Mikkila, Rasanen, Raitakari, Pietinen, & Viikari, 2004). This period
is also critical, as it is typically during this time that mental disorders emerge
for the first time (Kessler et al., 2005). Researchers around the world have
consistently demonstrated that the diet quality of young people is important
to mental health during the transition to adulthood ( Jacka et al., 2011, 2010;
Jacka, Rothon, Taylor, Berk, & Stansfeld, 2013; Kohlboeck et al., 2012;
Oellingrath, Svendsen, & Hestetun, 2014; Overby & Hoigaard, 2012;
Weng et al., 2012). Although requiring updating, existing systematic
reviews confirm a relationship between diet quality and mental health in
children and adolescence (ONeil et al., 2014). This evidence suggests the
importance of establishing healthy habits in early life and encouraging
replacement of snack-like foods with a diverse and nutrient-rich diet that
supports brain development and lays the foundation for a healthy adulthood
(Cutler, Flood, Hannan, & Neumark-Sztainer, 2009).
2.2 Diet and Mental Health in Adults and the Elderly

Dietary patterns in adulthood can be influenced by many social, demographic, and individual factors, and tend to be fairly firmly established
(Mikkila, Rasanen, Raitakari, Pietinen, & Viikari, 2005). This is an important period for lowering disease risk or managing health conditions through
lifestyle behaviors (Beaglehole et al., 2011; Stampfer, Hu, Manson,
Rimm, & Willett, 2000) and these health behaviors remain central to brain
and mental health during aging. A recent systematic review and metaanalysis
concluded that a healthy diet is significantly associated with reduced odds for
depression (Lai et al., 2014). Similarly, a metaanalysis of 22 studies investigating the protective effects of adherence to a Mediterranean-style diet on
brain diseases demonstrated that higher adherence was associated with a
reduced risk for depression as well as cognitive decline (Psaltopoulou
et al., 2013).

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Elderly individuals often experience changes in living situation, weakening social networks and are frequently managing chronic physically conditions, all of which contribute to the risk of depression (Huang, Wang, Li,
Xie, & Liu, 2011; Vink, Aartsen, & Schoevers, 2008). Age-related changes
to income, mobility, and nutrient absorption are important to nutrition
status in old age (Dean, Raats, Grunert, & Lumbers, 2009; Tiihonen,
Ouwehand, & Rautonen, 2010), and several studies have demonstrated
the importance of overall diet, particularly consumption of fruits and vegetables, to mental health in later life (Payne, Steck, George, & Steffens,
2012; Tsai, Chang, & Chi, 2012), while unhealthy dietary patterns are also
related to an increased risk of depression in this age group ( Jacka, Cherbuin,
Anstey, & Butterworth, 2014). The components of a good quality diet may
support natural changes to gut microbiota and cognitive function associated
with mental health (Claesson et al., 2012; Feart et al., 2009), whereas higher
intakes of unhealthy foods and lower intakes of healthy foods have both been
linked to reduced hippocampal volumea brain region important to mental
health as well as cognitive function ( Jacka, Cherbuin, Anstey, Sachdev,
et al., 2015).
While the observational evidence for a relationship between diet quality
and depression, in particular, is highly consistent and fulfills Bradford
Hill criteria for causality (Dash, ONeil, & Jacka, 2016; Jacka et al.,
2012), the nature of the association remains complex and is certainly bidirectional ( Jacka, Cherbuin, Anstey, & Butterworth, 2015). However,
recent intervention studies offer support for a causal relationship and support
dietary approaches to prevention and treatment. In particular, two recent
randomized controlled trials indicate the efficacy of dietary improvement
as a strategy for the prevention of depression (Sanchez-Villegas &
Martinez-Gonzalez, 2013; Stahl, Albert, Dew, Lockovich, & Reynolds,
2014), and a recent world-first trial has demonstrated the efficacy of diet
as a treatment strategy for depression (ONeil et al., 2013); these have important implications for the way we prevent, manage, and treat common mental
disorders. Given the strength and consistency of the dietmental health association in observational (and animal) studies, and the new intervention data
supporting causality, researchers are now investigating the plausible biological pathways that may mediate this relationship.
A primary focus of interest is now the gut and its resident microbiota,
given the strong relationship of diet to gut health and the emerging evidence
that gut microbiota play a role in influencing mood and behavior and the

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following section will focus on gut health in mental disorder and the imperative to take a dietary approach to improving gut-related factors.
3. THE IMPORTANCE OF DIET FOR GUT HEALTH

ACROSS THE LIFESPAN
Gut disturbances are common to mental and neurodevelopmental disorders (Dash et al., 2015). Gastrointestinal dysfunction and complaints are
observed in children with autism spectrum disorder (ASD) (de Magistris
et al., 2010) and microbial dysbiosis is reported in depression and anxiety
(Foster & McVey Neufeld, 2013), ASD (MacFabe, 2015; Rosenfeld,
2015), behavioral disorders (Lee & de La Serre, 2015; Shin, Whon, &
Bae, 2015), and bowel disease (Casen et al., 2015). Microbial dysbiosis refers
to disturbance in microbiota or abnormal hostmicrobiota interactions
(Lee & de La Serre, 2015; Petersen & Round, 2014) and may be characterized by loss of beneficial microbiota (Petersen & Round, 2014), low microbial diversity (Lee & de La Serre, 2015; Petersen & Round, 2014), and an
increase in pathogens, or proliferation of proinflammatory bacteria (such as
Proteobacteria) (Petersen & Round, 2014; Shin et al., 2015). Dysbiosis
increases intestinal permeability, which may serve to increase circulating
levels of lipopolysaccharide (LPS) (Cani & Delzenne, 2011). LPS is a metabolic endotoxin that triggers a neuroinflammatory response and promotes
low-grade inflammation (Qin et al., 2007). Inflammation is a proposed
underlying pathway for mental disorders (Frommberger et al., 1997;
Kivimaki et al., 2013; Pasco et al., 2010; Raison, Capuron, & Miller, 2006).
Across all ages, diet strongly determines microbiota composition
(Claesson et al., 2012; David et al., 2014; Laursen et al., 2016; Wu et al.,
2011). Importantly, diet is modifiable and microbiota composition responds
rapidly to dietary change (David et al., 2014). Dietary improvement toward
a healthy and diverse high fiber diet is thus of critical importance for promoting gut health (OKeefe et al., 2015).
3.1 The Influence of Diet on Early Life Microbiota

The greatest changes to the gut microbiota composition occur during early
establishment in infancy (from around birth until around the age of three)
(Yatsunenko et al., 2012), and in old age as dietary control and general health
conditions change (Claesson et al., 2012). In animals, poor quality maternal
gestational diets (such as high fat or low dietary fiber) reduces microbial
diversity in the offspring (Ma et al., 2014; Myles et al., 2013; Sonnenburg

331
et al., 2016) and increases colonic inflammation (Ma et al., 2014). Animal
data extensively support the relevance of the gut and early microbial colonization for the development of: the immune system (Arrieta et al., 2015;
Olszak et al., 2012; Thorburn et al., 2015); metabolism (Cox et al.,
2014); normal development of the HPA stress response (Sudo et al.,
2004); and brain barrier structure (Braniste et al., 2014). The same data
do not yet exist for humans, however modifying the maternal gut microbiota during pregnancy through probiotics modulates the expression of
Toll-like receptor genes in the placenta and in the fetal gut, indicating a link
with immune development (Rautava, Collado, Salminen, & Isolauri, 2012).
Many women do not meet dietary guidelines nor improve their diets during
pregnancy (de Jersey, Nicholson, Callaway, & Daniels, 2013; Hure, Young,
Smith, & Collins, 2009; Kaiser & Allen, 2002; Malek, Umberger,
Makrides, & Zhou, 2015) and it is unclear how this may impact on infant
microbial acquisition.
In animals, poor quality diets have an intergenerational effect on gut
microbiota (Sonnenburg et al., 2016). Low-fiber diets result in an intergenerational degradation of gut microbiota, such that dietary correction is
not possible after four generations of exposure to a western style diet
(Sonnenburg et al., 2016). How this relates to humans is unclear, however
those consuming industrialized diets have lower microbial diversity and they
are missing specific bacteria with genes for degrading plant polysaccharides
and xylans compared to those consuming ancestral style diets (De Filippo
et al., 2010; Schnorr et al., 2014). Although this does not attest to an intergenerational influence, it supports the contention that microbial diversity
may be at risk as dietary quality diminishes.
Delivery mode and breastfeeding status influence the early microbiota
(Azad et al., 2013). Breast milk contains human milk oligosaccharides
(HMOs), which have prebiotic potential. These HMOs are synergistically
metabolized by Lactobacillus and Bifidobacterium and this selectively promotes their growth (Koropatkin, Cameron, & Martens, 2012). Importantly,
breast milk transfers maternal mucosal memory to the infant via maternal
sIGA, and this may improve tolerance of commensals and resistance to pathogens as the infant gut microbiota establishes (Maynard, Elson, Hatton, &
Weaver, 2012). Dietary variety introduced at weaning introduces additional
glycans for microbial fermentation (Koropatkin et al., 2012). Indeed, gut
microbiota composition at 9 and 18 months is strongly influenced by
breastfeeding duration, the composition of the complementary diet and
the transition to family foods (Laursen et al., 2016). These factors were more

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important than vertical transmission from the mother, birth mode, gestational age, or maternal obesity in determining microbial composition and
diversity (Laursen et al., 2016). Foods high in protein and fiber increased
alpha diversity and altered microbial composition, while fat intake negatively correlated with diversity.
3.2 The Western Diet Has a Detrimental Influence on Adult

Gut Health
The importance of diet for gut health is demonstrated by OKeefe and
colleagues cross-over dietary study (OKeefe et al., 2015). This study
highlights the detrimental effect of the western diet on colonic health.
Twenty African Americans and 20 rural South Africans exchanged diets
for 2 weeks: both groups consumed a western diet consisting of 14 g/day
of fiber and a plant-based rural African diet consisting of 28 g/day of fiber,
plus 38 g/day resistant starch (OKeefe et al., 2015). The western diet
reduced microbial diversity, reduced butyrate production, and significantly
increased gut mucosal inflammation (OKeefe et al., 2015). Conversely the
high fiber, rural African diet promoted colonic health, characterized by a
reduction in inflammation and also increased saccharolytic fermentation
and production of SCFAs (particularly butyrate due to the resistant starch
load) (OKeefe et al., 2015). The beneficial effect on colonic health attributed to the plant-based diet is likely due to butyrate, given its role in resolving inflammation, reducing oxidative stress, maintaining the colonic
epithelium, and intestinal mucous barrier (Hamer et al., 2008; Maslowski
et al., 2009).
Low intake of fiber and high intakes of fat and protein are characteristics
of the western diet that are particularly damaging to gut health. In mice, high
fat feeding (72% fat, 28% protein, and <1% carbohydrate) altered the gut
microbiota, increased intestinal permeability, and promoted metabolic
endotoxemia (Cani et al., 2008). In humans, high animal fats and protein
intakes influence gut microbiota composition toward bilophilic species,
such as the sulfite-reducing species Bilophila wadsworthia, which is implicated
in inflammatory bowel disease (David et al., 2014; Flint, Duncan, Scott, &
Louis, 2014). High protein, low carbohydrate diets are also implicated in
increasing N-nitrosamine production, a carcinogen related to colon-cancer
risk (Russell et al., 2011).

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3.3 Beneficial Influence of Plant-Based Diets on Adult

Gut Health
The carbohydrate content of plant-based diets is important for promoting
gut health due to the presence of nondigestible dietary fibers. Carbohydrates
classify as a prebiotic when they are a nondigestible compound that,
through its metabolization by microorganisms in the gut, modulates composition, and/or activity of the gut microbiota, thus conferring a beneficial
physiological effect on the host (Bindels, Delzenne, Cani, & Walter, 2015).
Examples of prebiotics are inulin and fructooligosaccharides (found in foods
such as asparagus, leek, onion, artichoke, and wheat; Eswaran, Muir, &
Chey, 2013), transgalactooligosaccharides (a manufactured product), and
human breast milk (Bindels et al., 2015). These are fermented by gut microbiota to result in SCFA production (Bindels et al., 2015). Foods containing
prebiotic fiber (such as inulin, fructooligosaccharides) may also improve
intestinal barrier function and decrease intestinal permeability and metabolic
endotoxemia by increasing endogenous production of glucagon-like peptide-2 (GLP-2) (Cani & Delzenne, 2011; Russo et al., 2012). Moreover,
plant polyphenols (i.e. present in tea, berries, and other fruit) have prebiotic
potential and modulate gut ecology by inhibiting the growth and colonic
adherence of specific pathogenic bacteria, and stimulating the growth of species associated with gut mucous layer thickness (such as Lactobacillus spp.,
Bifidobacterium spp., and Akkermansia muciniphila) (Anh^e et al., 2015;
Parkar, Stevenson, & Skinner, 2008).
In industrialized societies, the Mediterranean diet exemplifies a healthy
dietary pattern that is beneficial to gut health (De Filippis et al., 2015). Highlevel adherence to the Mediterranean diet, consisting of fresh plant-based
foods, moderate in fish, olive oil, and eggs and low in saturated fat and
red meat, is associated with a healthier microbiota and higher levels of short
chain fatty acids when compared to a western diet (De Filippis et al., 2015).
The Mediterranean diet has a low inflammatory potential (Schwingshackl &
Hoffmann, 2014), and promotes an abundance of saccharolytic microbiota
and, consequently, high fecal concentrations of butyrate, propionate, and
acetate (De Filippis et al., 2015; Gutierrez-Diaz, Fernandez-Navarro,
Sanchez, Margolles, & Gonzalez, 2016). These mechanisms may partially
explain the relationship between adherence to a quality Mediterranean diet
and reduced risk of depression and cognitive impairment (Psaltopoulou
et al., 2013).

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4. OPPORTUNITIES FOR PREVENTION AND TREATMENT

OF MENTAL HEALTH DISORDERS
4.1 Dietary Strategies for the Prevention of Mental
Disorders: A Public Health Perspective
The rise in mental disorder burden has been met with campaigns to reduce
stigma and increase awareness, however few specific, action-oriented prevention strategies have been developed or implemented ( Jacka, Reavley,
et al., 2013). Psychiatric epidemiology has focused primarily on understanding the etiology of common mental disorders and has been slow to develop
primary prevention strategies to be implemented at a population level
(Galea, 2013; Jacka, Reavley, et al., 2013), despite the identification of several key prevention opportunities (Shonkoff, Boyce, & McEwen, 2009).
Given the shared risk factors and high comorbidity of physical and mental
conditions, there have been calls for a shared framework for the prevention
of common mental and noncommunicable disorders (ONeil et al., 2015). It
is essential that mental health prevention is integrated within existing programs for disease prevention and control, for example obesity or cardiovascular disease, in order to provide a cost effective strategy that is likely to
benefit both mental and physical disorders. Taking lessons from previous
public health campaigns, a top-down approach that implements change at
a government and policy level is important to success (Brownson,
Chriqui, & Stamatakis, 2009). While this is important, policy change can
be slow to develop, and we must also develop clear and specific recommendations that can be implemented at a community, organizational, and individual level. Such recommendations are beginning to emerge (Dash et al.,
2016; Opie et al., 2015).
From a developmental origins of health and disease perspective, it is
important to implement prevention strategies in the earliest stages of human
life (Barker, 2015; Gillman, 2005; Hanson & Gluckman, 2011). The early
life period is characterized by high developmental plasticity and is influenced
by in utero environmental factors (Hanson & Gluckman, 2011). This period
is therefore an important target for health interventions aiming to influence
predisposition to noncommunicable diseases (Hanson & Gluckman, 2011).
Nutrition is a key in utero factor influencing brain development and subsequent disease risk (Bale et al., 2010; Schlotz & Phillips, 2009), and thus
addressing prenatal diet quality is important. Dietary prevention or treatment strategies may improve maternal nutrition, but these improvements

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do not always transfer to children (Vahamiko et al., 2013). To address

the developmental origins of health and disease, policy strategy and prevention
initiatives must focus on improving health literacy and fostering nutritional
empowerment early in life (Barker, 2015; Hanson & Gluckman, 2011).
The focus for nutritional interventions may best be shifted away from women
of childbearing age to girls and young women because early attainment of
healthy diet may promote life-long sustainable dietary improvement
(Barker, 2015). Children and young women may then be empowered to
make positive dietary choices, and these behaviors are anticipated to influence
their families and social groups. Over time this may gain momentum such that
politicians and commercial organizations are prompted to respond and
improve the food environment (Barker, 2015; Hanson & Gluckman, 2011).
4.2 Targeting Early Life Gut Microbiota

Targeting prevention strategies toward the maternal gut microbiota is relevant for influencing in utero microbial exposure and early life microbial colonization (Rautava et al., 2012). Prenatal probiotic supplementation has
been shown to influence maternal and infant gut microbiota in some trials
(Gr
onlund, Grzeskowiak, Isolauri, & Salminen, 2011; Lahtinen et al., 2009)
but not all (Wright & Starkweather, 2015). Given that diet rapidly influences
the composition of the microbiota (David et al., 2014), we speculate that
targeting maternal gut health through a dietary intervention delivered during pregnancy may modulate maternal and infant microbiota. Increasing
intake of fibrous plant-based foods (grains, vegetables, beans and legumes,
fruit, and nuts) and fermented foods, and reducing intakes of refined foods
are central to gut health, therefore interventions may center around the
Mediterranean diet, or other forms of healthy diet (Opie et al., 2015). Dietary improvement is protective of maternal mental health (Opie et al., 2015)
and as such may be superior to prebiotic or probiotic supplementation alone.
In infancy, the establishment of a healthy gut microbiota may be relevant for neurodevelopmental outcomes (Borre et al., 2014). In animals,
microbial modulation of mice during weaning improves symptoms of
neurodevelopmental disease (Hsiao et al., 2013), and emerging evidence
suggests that targeting infant microbiota through probiotics reduces the risk
of attention deficit hyperactivity disorder (ADHD) and Asperger syndrome
(Partty et al., 2015) although further research is required. Certainly birth
mode and feeding strategies shape early microbial composition, however
transition to the family diet appears to be an important determinant of

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microbial diversity in infancy (Laursen et al., 2016). Therefore, care should

be taken during complimentary feeding to transition to a high quality diet
that includes good sources of dietary fiber and protein (Laursen et al., 2016).
4.3 Dietary Targeting of Mothers for Reducing the Risk

of Mental Disorders in Children
Diet quality is generally poor during pregnancy because the dietary guidelines are rarely met (de Jersey et al., 2013; Hure et al., 2009; Kaiser & Allen,
2002; Malek et al., 2015). Poor quality diets are also associated with
increased maternal depressive symptoms (Baskin et al., 2015), and they
are independently related to poorer emotional, cognitive (Barker et al.,
2013), and behavioral outcomes in young children ( Jacka, Ystrom, et al.,
2013; Pina-Camacho et al., 2015; Steenweg-de Graaff et al., 2014). Interventions aiming to treat prenatal depression should include a dietary focus
(Barker et al., 2013). Opie and colleagues dietary recommendations for
preventing depression could be incorporated into dietary interventions with
a focus on traditional dietary patterns, increased intake of plant-based foods
and omega-3 polyunsaturated fatty acids, along with reducing intake of
refined foods (Opie et al., 2015). These recommendations are expected
to promote a healthy microbiome, because are congruous with dietary patterns that have been consistently associated with a healthier gut microbiota
(De Filippo et al., 2010; Martnez et al., 2015; Obregon-Tito et al., 2015;
OKeefe et al., 2015; Schnorr et al., 2014; Yatsunenko et al., 2012). Thus,
targeting gut health in pregnant women by improving diet may have important benefits to the gut health of children, given the transmission of microbiota to infants before and during birth.
Poor diets also drive the pathogenesis of inflammatory metabolic conditions such as obesity, type 2 and gestational diabetes. These conditions are
risk factors for neurodevelopmental disorders (Krakowiak et al., 2012;
Suren et al., 2014; Van Lieshout, Taylor, & Boyle, 2011; Van Lieshout &
Voruganti, 2008), therefore mothers at risk of gestational diabetes mellitus
(GDM) and obesity should be targeted for treatment. During pregnancy,
dietary counseling with probiotic supplementation of Lactobacillus rhamnosus
GG and Bifidobacterium lactis has been seen to improve maternal glucose regulation and reduce the incidence of GDM (Laitinen, Poussa, & Isolauri,
2008). When GDM was present, dietary counseling reduced the risk of large
birth size (Luoto, Laitinen, Nermes, & Isolauri, 2010), this may improve the
chances of vaginal delivery which is beneficial for healthy microbial acquisition (Dominguez-Bello et al., 2010).

337
Similarly, managing obesity by targeting weight loss and gut health during pregnancy may be relevant for reducing childhood risk of cognitive
problems, ADHD symptoms, adolescent eating disorders, and adulthood
psychotic disorders (Van Lieshout et al., 2011). Dietary interventions delivered during pregnancy are effective for reducing gestational weight gain and
reducing cesarean section incidence (Tanentsapf, Heitmann, & Adegboye,
2011). During pregnancy, dietary strategies may be adopted to treat the lowgrade exdotoxemia and metabolic inflammation that is characteristic of
pregnant obese women (Basu et al., 2011; Dewulf et al., 2013). To limit
infant exposure to maternal immune activation, the inclusion of prebiotic
dietary inulin-type fructans in prospective dietary interventions may modulate microbiota and assist with the management of low-grade exdotoxemia
metabolic inflammation (Dewulf et al., 2013). Managing obesity during
pregnancy may improve infant gut health because compared to lean controls, the microbiota of infants born to obese mothers differs and has greater
proinflammatory activity (Collado, Isolauri, Laitinen, & Salminen, 2010).
However, later transition to family foods appears to exert a greater influence
over infant microbiota than maternal obesity (Laursen et al., 2016).
4.4 Diet as a Treatment for Mental Health

Medication and psychological intervention remain the primary forms of
treatment for mental disorders, although evidence suggests the efficacy of
these strategies has been overestimated (Cuijpers, Smit, Bohlmeijer,
Hollon, & Andersson, 2010; Gelenberg, 2010). Lifestyle Medicine targets
modifiable risk factors for mental disorders as a low risk, cost effective, and
integrative strategy for the treatment of mental illness (Sarris, ONeil,
Coulson, Schweitzer, & Berk, 2014). This treatment approach requires
the development of appropriate diagnostic tools that incorporate assessment
of health behaviors, for example physical activity and diet quality, in order to
identify populations particularly at risk and encourage early intervention.
Dietary and lifestyle (i.e. exercise and smoking) recommendations as well
as dietetic services should be a standard component of care for at risk patients
and as well as those with current MDD and this understanding has been
incorporated into recent updates to Clinical Practice Guidelines in Australia
(Malhi et al., 2015).
Results of a recent randomized controlled trial support dietary strategies
for the treatment of depression, demonstrating highly significant results in a
relatively short period of intervention (ONeil et al., 2013). It will be

338
S.L. Dawson et al.
important to replicate these key findings, however, given the strength and
consistency of the evidence for the dietdepression association, it is now
critical to translate evidence to action (Dash et al., 2016). Furthermore, continuing explication of the key biological mechanisms of action that underpin
the dietdepression association, such as the gut microbiota, is important for
developing targeted treatment and prevention strategies (Schmidt,
Shelton, & Duman, 2011).
5. CONCLUSION
This chapter highlights the importance of diet to mental and gut health
across the lifespan. The emerging and established evidence now strongly
supports taking a dietary approach to the prevention and management of
highly prevalent mental disorders. Future work in this new field of nutritional psychiatry research should focus on replication, the scaling up of interventions, and further identification of the pathways that mediate the impact
of dietary improvement on depressive illness. The evidence clearly supports
the gut and its resident microbiome as a key target for research and intervention. Public health approaches and messages should now focus on the importance of diet for mental as well as physical health, while clinicians should
promote the benefits of dietary improvement and facilitate access to dietary
support for their patients. Finally and critically, given the likely causal role
of diet in depressive illness and the global burden of this disabling disorder,
policy makers should urgently make the necessary changes to improve access
to quality food and reduce access to the unhealthy and processed food products that are made ubiquitous and heavily promoted by industry.
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