CHAPTER TWELVE

Building Your Antianxiety Eating Plan

When my patients first come into my clinic, they are often confused about what to eat. It’s not hard to see why. The loudest voices in the diet wars are constantly competing to have the newest advice about the exact right way to eat, churning out a steady stream of content that promises a one-size-fits-all solution. When I tell my patients there is no magic diet or secret sauce that will immediately and definitively cure anxiety forever, I understand why they might feel a little disappointed. There is comfort in the idea of a set of instructions that fix a problem with no threat of uncertainty.

But while no diet is a magic bullet for every single person, there is value in some of the popular diets that are buzzed about in the media. In fact, the two diets my patients ask about most are the same two that have the best grounding in science and research: the Mediterranean diet and the ketogenic diet. While the principles of the two diets are quite different, they can both be shaped around the Six Pillars to form the basis of a personalized antianxiety eating plan that’s right for you. In this chapter, we’ll consider the strengths and weaknesses of each diet and break down ways to fit them more snugly into the framework of our Six Pillars. We’ll also go over some good eating practices to implement no matter what plan you choose to follow.

THE BEST PLACE TO START FOR MOST PEOPLE: THE MEDITERRANEAN DIET

The Mediterranean diet is based on the traditional diets of cultures located around the Mediterranean Sea, including Greece, Italy, southern France, Spain, and parts of the Middle East—including the Blue Zones of Sardinia, Italy, and Ikaria, Greece. In the mid-1950s, scientist Ancel Keys sought to figure out why the poor population of southern Italy was so much healthier than the much wealthier population of New York City. His initial curiosity led to the famous Seven Countries Study, which studied the diets of the United States, Finland, Yugoslavia, Japan, the Netherlands, Italy, and Greece. The Seven Countries Study is acknowledged as the first major study to link diet with cardiovascular disease, and it found that diets from the Mediterranean region were the most heart-healthy.1

In the 1960s, this research resulted in the development of a diet inspired by Mediterranean cultures, heavy in olive oil, fruit, vegetables, legumes, whole grains, and fish. While the Mediterranean diet has been refined and modified over the years, it is still very much a touchstone of good health. Though long-term studies of complex diets are notoriously difficult to perform due to extended time frames and endless dietary variables, the Mediterranean diet’s anti-inflammatory properties and positive effects on cardiovascular and metabolic health have been confirmed many times over. In just one example, a 2020 review found that following the Mediterranean diet led to improved metabolic health in those suffering from type 2 diabetes, as well as a whopping 30 percent reduction in heart attack and other major cardiovascular events.2 It also leads to a more diverse gut microbiome compared to the standard American diet.3

The foods that make up the Mediterranean diet align well with the Six Pillars. It is built around whole foods and includes a wide variety of vegetables, micronutrients, and healthy fats, without including large amounts of anxiety-inducing red flags like added sugars and other high-glycemic-index carbs. As with all associations between diet and mental health, the Mediterranean diet’s effect on conditions like anxiety have only been recently studied in earnest. Unsurprisingly, there are strong indications that the Mediterranean diet is beneficial for depression and anxiety.4 One long-term Swedish study followed almost one hundred thousand Swedish women for twenty years, tracking their adherence to the diet. Results showed that participants who had higher adherence to the Mediterranean diet were less likely to be diagnosed with depression, especially serious depression.5 While there hasn’t been a similar long-term study on anxiety specifically, since these conditions are so closely linked, I feel strongly that it is a good choice for reducing anxiety, too.

In other words, in theory, faithfully following a Mediterranean diet plan is a viable strategy for eating all the foods necessary for a calm mind. In fact, the Mediterranean diet probably is the closest we have gotten to the magical one-size-fits-all diet for general health, so it makes sense that it is so commonly recommended by doctors and dietitians, including myself.

However, it’s important to acknowledge the Mediterranean diet’s weakness: a lack of flexibility. While its components might be universally healthy, that doesn’t mean every person will find it easy to follow and enjoy. Its reliance on seafood and dairy makes it difficult for vegetarians and vegans to follow faithfully. Moreover, a diet based heavily on traditional Mediterranean foods and flavors is simply not going to be a perfect fit for everyone. After a lecture on the benefits of the Mediterranean diet, one of my very smart med students in the Division of Nutrition at Harvard asked me why the Mediterranean diet is so universally recommended, given that many cultures eat very different food. Being Asian, she wasn’t interested in revamping her diet around Mediterranean principles, nor did she feel comfortable suggesting that her patients from a diverse range of cultures do so. That made me realize that I feel the same way; though there are many traditional Mediterranean foods and dishes that I love, I would never want to be cut off from the South Asian cuisine I grew up with, or any other world cuisine for that matter.

Sure enough, when I see my patients struggle with the Mediterranean diet, it’s often because of conflicts with Pillar 6: Find Consistency and Balance. If the Mediterranean diet doesn’t match up with your preferences due to cultural reasons, dietary restrictions, or personal taste, it can be difficult to stick with it consistently. And even if you don’t have a strong connection to your own cultural food tradition, you want to make sure you’re taking advantage of the ability to eat healthy foods from around the globe—for instance, the avocados and black beans of Latin American cuisine, the nori and miso of East Asian cuisines, and the dal and spices of South Asian cuisines. All of those are excellent foods to fight anxiety, so there’s no reason to leave them out simply because they aren’t traditional Mediterranean foods.

Happily, there are many options for expanding the confines of the Mediterranean diet to incorporate different foods, while still following the guidance of the Six Pillars. For instance, researchers and recipe developers have explored hybrid MediterrAsian diets that seek to combine the fundamentals of the Mediterranean diet with foods from traditional Asian diets, providing room for different flavors as well as the bioactives in soy, seaweed, green tea, and turmeric, which can enhance the effects of the traditional Mediterranean diet.6 In my own cooking and clinical work, I’ve had great success in adding healthy South Asian foods, Korean and Japanese flavors, and other diverse twists to the basics of the Mediterranean diet—which are reflected in the recipes in this book.

To see that in action, let’s break down the specifics of an eating plan that synthesizes the Mediterranean diet with a variety of foods and flavors from around the world, all while fitting the framework of the Six Pillars. Since the strengths of the Mediterranean diet are so universal, this Mediterranean-inspired eating plan is what I would first recommend to someone who is just starting the journey to calming their mind with food—and it is the inspiration for the recipes in chapter 14.

THE MEDITERRANEAN-INSPIRED ANTIANXIETY EATING PLAN

Eat Daily:

These daily foods will form the foundation of your antianxiety diet, providing you with a good balance of macronutrients, micronutrients, healthy fats, and fiber.

image Eat at least two different fresh vegetables with every main meal, for a total of 6–8 servings of vegetables daily. Prioritize 1 cup servings of raw, leafy greens (spinach, arugula, romaine) and ½ cup servings of lightly cooked cruciferous vegetables (broccoli, Brussels sprouts, cauliflower), mixing in brightly colored vegetables like bell peppers, tomatoes, carrots, cucumbers, and zucchini, as well as garlic, leeks, and onions.

image Eat 2 servings of fruit daily, either as part of a meal or as a snack or dessert. My favorite single servings of fruit are ¼ cup blueberries; ¼ cup combination of raspberries, blackberries, and strawberries; a small to medium apple; a clementine; or a small orange.

image Daily protein requirements can be calculated using the dietary reference intakes calculator from the USDA (https://www.nal.usda.gov/human-nutrition-and-food-safety/dri-calculator), but you should consult with your doctor, as protein requirements can change with different medical conditions. The best everyday sources of protein are plant-based, for example, 4 ounces organic, non-GMO tofu (about 9 grams of protein); ½ cup lentils (about 9 grams of protein); ½ cup kidney, black, navy, or cannellini beans (about 8 grams of protein); or ½ cup chickpeas (about 6 grams of protein).

image If you choose to eat animal protein, try to keep two meals per day plant-based, and then eat 1 serving of meat, fish, poultry, or eggs at your third meal. Options are 3–4 ounces wild-caught salmon (about 30 grams of protein), 4–5 ounces pasture-raised chicken or turkey (about 30 grams of protein), 4 ounces grass-fed beef (about 33 grams of protein), or 1–2 pasture-raised eggs (12 grams of protein).

image Extra-virgin olive oil: 1–2 tablespoons in salad dressings and other low-heat uses; avocado oil for higher-heat cooking.

image Nuts (walnuts, pecans, almonds): about ¼ cup.

image Seeds (flaxseeds, chia seeds, hemp seeds): about ¼ cup.

image Fermented foods (pickles, kimchi, sauerkraut): ¼ cup

image Tea (lavender, passionflower, chamomile, golden chai): 1–2 cups.

Eat a Few Times per Week:

These foods shouldn’t be eaten every day, but they are still good components of an antianxiety diet and can be eaten two to four times per week.

Dairy, preferably grass-fed: ½ cup milk, cottage cheese, or plain yogurt; or 1 ounce Parmesan cheese (plant-based milk, yogurt, and homemade cheese substitutes all work for those who prefer a plant-based diet).

Avocado: ¼ medium-size avocado.

Chocolate: 1½ ounces extra-dark chocolate as a brain-healthy post-meal treat.

Eat No More than Three to Four Times Per Month:

While these foods are not staples, they can be eaten in moderate portions once a week or less. Pay attention to your body intelligence after eating these foods. If you feel nervous, jittery, or cranky after eating starches or grains, cut them out entirely.

Bread and pasta made from wheat flour: 1 slice of bread (preferably sourdough), or 2 ounces dried pasta (cooked and thoroughly cooled before reheating to eat).

White or brown rice: ½ cup or less cooked rice.

Potatoes and sweet potatoes: 1 medium-size potato, baked, boiled, or roasted rather than fried (cooked and thoroughly cooled before reheating to eat).

Meat substitutes: 1 serving as indicated on packaging.

Always Avoid:

These foods and beverages are ubiquitous and tempting, but it’s important to avoid them as much as possible, as all can be major anxiety triggers.

image Processed and packaged foods like breakfast cereals, granola bars, chips, and crackers

image Processed meats and cheeses, including sliced deli meat and American cheese

image Sweets like cookies, cakes, and candy, including those sweetened with artificial sweeteners

image Sweet drinks, including soda (regular and diet), fruit juice, energy drinks, and sports drinks

A Sample Meal Plan

Turning those guidelines into a set of real-life meals is the fun part. Here is a sample seven-day meal plan that follows the Six Pillars and combines the healthy foods of the Mediterranean diet with foods and flavors from around the world.

Snacks (choose 1–2 per day):

image 2 tablespoons Brain-Food Granola (here) with yogurt or cottage cheese

image ¼ cup blueberries or other mixed berries

image ½ cup organic grassmilk cottage cheese with a sprinkle of cinnamon

image ½ cup grassmilk dairy or nondairy yogurt with cinnamon or plain applesauce and a drop of manuka honey

image Sliced Fuji apple with 1 ounce Parmesan cheese

image 2 tablespoons hummus with celery sticks

Monday

image Breakfast: Basil Seed Pudding (here) with blueberries and almonds

image Lunch: Korean-Inspired Shrimp (here) with a side of Pan-Seared Purple Sprouting Broccoli (here)

image Dinner: Show-Stopping Roasted Head of Broccoli (here) with steamed garlicky spinach

Tuesday

image Breakfast: Two-egg omelet or Chickpea Scramble (here) with spinach, scallions, and mushrooms

image Lunch: Dr. Uma’s Crunchy Kaleidoscope Salad (here) topped with Shiitake Bacon (here)

image Dinner: Sambar (Dal) (here) with vegetables; Go-To Calm Green Salad (here) with veggies, nuts, and seeds

Wednesday

image Breakfast: Yogurt (dairy or nondairy) and berries with cinnamon and a touch of manuka honey

image Lunch: Korean-Indian Baked Chicken (here) with Spicy Crunchy Cucumber Salad (here); or substitute non-GMO organic tofu or Burmese Chickpea Tofu (here) for chicken

image Dinner: Mixed salad with shredded red cabbage, carrots, sliced cucumbers, and grape tomatoes; and Baked (and Cooled) Potato (here) with chopped scallions, crème fraîche, and grated Parmesan cheese

Thursday

image Breakfast: Quinoa Cereal (here) topped with berries

image Lunch: Healthy-ish Mac and Cheese (here) with a side green salad

image Dinner: Spaghetti Squash Noodles with Walnut “Pesto” (here), or add sautéed ground turkey; and chopped vegetables with Crispy Tikka Masala Tofu (here)

Friday

image Breakfast: Chopped avocado with tomatoes and lettuce on sourdough toast, and ¼ cup blueberries

image Lunch: 6 ounces Burmese Chickpea Tofu (here) stir-fried with mixed veggies and seasoned konjak Miracle Rice

image Dinner: Cauliflower seasoned with South Asian tikka masala spice blend—just omit the tofu from the recipe here—with air-fried Crispy MediterrAsian Okra Fries (here) and arugula salad

Saturday

image Breakfast: Tofu, spinach, and red pepper scramble (substitute 2 pastured eggs instead of tofu, if desired); and sliced strawberries

image Lunch: MediterrAsian-Inspired Eggplant (here) with Miso-Infused Cipollini Onions and Green Beans (here)

image Dinner: Creamy Cannellini Bean and Greens Soup (here), baby bok choy, and romaine salad

Sunday

image Breakfast: Dr. Uma’s Cherry CALM Smoothie (here)

image Lunch: Curried Cauliflower and Coconut Soup (here) with microgreens; side of roasted crispy chickpeas

image Dinner: Konjak Miracle Noodles with peanut sauce and shaved veggies, or add chopped grilled chicken, tofu, chickpeas, or beef

That’s a week’s worth of meals to keep your mind calm and your tastebuds engaged, following the Six Pillars and the basics of the Mediterranean diet without being tied down to the foods and flavors of a single region.

A LOW-CARB OPTION: CLEAN KETO

Many of my patients are interested in low-carb diets, attracted by their reputation for helping people lose weight. In particular, I’m often asked about the ketogenic diet, a low-carb, high-fat diet that has taken the diet world by storm. While I don’t think the restrictiveness of the keto diet is necessary for most people, in situations where a patient’s anxiety doesn’t respond to a Mediterranean-based eating plan, or weight loss is a priority, there is enough compelling evidence on keto’s benefits to mental health that I believe it’s worth a try—at least as long as it is adapted to uphold our Six Pillars.

Given its sudden explosion in popularity, you might think the ketogenic diet was a recent invention. But in fact, it was developed as a treatment for epilepsy in the 1920s, with roots that date back to ancient times. The goal of the keto diet is to essentially mimic fasting, tricking your body into thinking it’s not getting enough sustenance, convincing it to burn fat for fuel. When you reduce your levels of carbohydrates to less than 15 percent of your caloric intake, your body doesn’t have its usual flow of glucose to power the processes of life. In the absence of its favorite fuel, it turns to burning fat for energy. When controlled through careful dieting, this begins a process called nutritional ketosis (a state of uncontrolled ketosis is called ketoacidosis, which can be harmful and even life-threatening). Your liver creates compounds called ketones, which substitute for glucose as the power source for your brain and body. If you weren’t eating at all, ketosis wouldn’t be sustainable; your fat reserves would eventually be exhausted, and you would be in major trouble. However, if you followed the keto diet, you’d be significantly lowering carbs but constantly ingesting calories from fat (and to a lesser degree protein), which would allow your body to sustain nutritional ketosis indefinitely. Essentially, you’d be switching your body’s fuel source from glucose to fat.

The fat-burning process of nutritional ketosis is why the keto diet is so effective at promoting weight loss. However, we now also have a greater understanding of its effects on the brain and its possibilities for reducing anxiety.7 There is evidence that the keto diet helps reduce inflammation, as well as limiting oxidative stress.8 The theory is that the metabolism of ketones results in less harmful free radicals than glucose metabolism, and this lowers your risk of chronic inflammation.

Studies of the keto diet’s impact on mental health have been encouraging: one comprehensive review into the effects of the keto diet on a range of psychiatric conditions, including depression, bipolar disorder, and schizophrenia (unfortunately, anxiety was not included), found that every single study showed positive mental health effects.9 Another study found that the diet significantly improved depression and anxiety in patients with Parkinson’s disease.10 Still, our understanding of the keto diet’s long-term effects on mental and physical health are relative unknowns given how recently it has risen to prominence. For instance, research into how the keto diet affects the gut microbiome has been mixed, with some studies showing that it enhances diversity of gut bacteria and others showing that it impedes it.11

Since so much of a high-fat diet flies in the face of traditional dietary advice, I can see why many health practitioners have been cautious about recommending it. That being said, I am excited about what new research will show, and I do think the keto diet is here to stay as a powerful short-term dietary tool to help anxiety as needed.

CLEANING UP THE KETO DIET

Unlike the Mediterranean diet, keto diets aren’t defined by specific foods, instead focusing on a specific breakdown of macronutrients. For example, a typical keto diet may specify that you eat 55–60 percent of calories from fat, 30–35 percent of calories from protein, and 5–10 percent of calories from carbs.12 But keto diet plans don’t always specify the sources of those macronutrients, which can lead unaware dieters to unhealthy food choices—particularly unhealthy fats, like pro-inflammatory omega-6 PUFAs. To complicate matters, many food producers have capitalized on the rise of keto diets to market packaged foods as keto-friendly, even though they are highly processed and often include artificial sweeteners.

Therefore, when my patients are curious about trying the keto diet, I recommend a variation called “clean keto,” which strives to meet the dietary components of the keto diet while also emphasizing healthy food. As with the Mediterranean diet, fats should largely come from olive oil, oily fish, avocados, nuts, and egg yolks. Protein comes from dairy, unprocessed meat, and eggs. The small amount of carbs comes from complex, low-glycemic sources like asparagus, spinach, mushrooms, lettuce, and tomatoes, which also contain dietary fiber.

Adapting our Mediterranean-inspired eating plan to fit a clean keto mold requires a number of changes to increase fat consumption and restrict carbs.

image The biggest omission from a Mediterranean-inspired diet is legumes. Beans, chickpeas, and lentils are all too carb-heavy to be included on a keto diet. However, most other protein sources, like tofu, poultry, meat, and seafood are allowed.

image A wide variety of vegetables is still crucial on a clean keto diet—especially since you’re cutting out many other good sources of dietary fiber like beans. Leafy greens, cruciferous vegetables, asparagus, bell peppers, mushrooms, onions, garlic, and other low-carb vegetables are allowed. However, you will need to totally avoid starchy vegetables like potatoes, sweet potatoes, corn, beets, and peas.

image Fruits are not allowed. Some keto diets do allow for small amounts of berries, but no other fruits. Increasing intake of healthy fats means consuming more olive oil, nuts, seeds, and avocados. While plant-based fats are always important to include, keto diets are easier if you eat animal fats, especially full-fat dairy and omega-3 fats from salmon and other seafood.

image Grains like wheat and oats should be completely avoided. No bread or pasta.

Keto is not for everyone, and I understand that many are leery of the fad-diet messaging surrounding it and skeptical that eating large amounts of fat is the key to good health—and there are certainly medical researchers who have called into question the long-term wisdom of low-carb diets.13 Because of these concerns, and because of the level of dedication it takes to stick to a keto diet, in my clinic I reserve the clean keto plan for individuals who have tried a more general Mediterranean-style diet and continue to struggle with both anxiety and weight gain. As they begin to follow clean keto, they are carefully assessed during a trial period to ensure that they can handle the food restrictions while still managing to properly nourish themselves.

While there is reason for caution, if your anxiety hasn’t responded to other, less radical dietary interventions, I encourage you to work with a dietary practitioner to develop a plan for a clean keto diet. It could potentially have a major effect on your mental health.

INTERMITTENT FASTING

Along with the keto diet, another rising star in the nutritional world is the concept of intermittent fasting, a dietary practice that has gained a fervent following in recent years for its potential to promote weight loss and improve metabolic health. The basic idea of intermittent fasting is that you eat only during certain windows of time. While there are many variations of intermittent fasting, they all involve eating only in planned intervals, punctuated by periods of fasting where you eat very little or nothing at all. For example, a daily intermittent fasting plan might involve eating for eight hours of the day, then fasting for the following sixteen hours. Another popular approach is the 5:2 plan, where you eat normally five days a week while eating only minimal calories on the other two.

The science on intermittent fasting is not ironclad at this point, but there is promising research that suggests it can be a valuable tool for weight loss, metabolic health, and leptin function, all of which we know can be beneficial for anxiety.14 There has also been research into the effects of intermittent fasting on anxiety directly, largely stemming from studies surrounding the Islamic holiday of Ramadan, where adherents ritually fast from dawn to dusk. Though religious fasting stems from a different mindset than fasting for general health, it’s still promising to see that these studies show a positive effect on depression and anxiety.15

There is also evidence that intermittent fasting is beneficial to the diversity of your gut microbiome. Gut microbiota composition fluctuates cyclically throughout the day, and certain eating patterns, like eating close to bedtime, can disrupt these fluctuations, leading to a reduction in microbiome diversity. Intermittent fasting has been shown to normalize patterns in your microbiome and lead to greater diversity, which in turn can help reduce anxiety.16

In the absence of more direct research tying intermittent fasting to a reduction in anxiety, it’s not something I recommend to every one of my patients. But if a patient is suffering from anxiety and metabolic disruption, it can provide an additional lever to pull alongside changes to diet. If you’re curious about trying intermittent fasting, it’s worth speaking to a health practitioner to help you develop a plan. While there are several safe methods of intermittent fasting, restricting calories for long periods can be dangerous, especially for people with conditions like diabetes, so it’s important to get professional guidance.

GOOD EATING PRACTICES

In addition to choosing foods and planning meals based on the Six Pillars, the final piece of your antianxiety diet is establishing good eating practices to help ensure that meals are a time of calm and free of stress. First, let’s return to the wisdom of the Blue Zones, to think about some ways in which the rules of the Power 9 that don’t directly pertain to food can be viewed through a dietary lens.

image Community: A sense of belonging and a commitment to family and other loved ones are central focuses of the Power 9. For us, this means finding a caring and comfortable community to eat with. That will look different for everyone! For some, it may be the classic family dinner. For others it may be a larger group of people in a church or community group who come together to celebrate food. For still others it may mean joining a friend on video chat for a shared meal, one of the positives that modern technology enabled during the COVID-19 pandemic, one that will remain useful in our increasingly far-flung society.

image Downshifting: Residents of the Blue Zones reduce stress by finding opportunities to step away from the pressures of the day. I encourage you to use mealtimes as a chance for respite and relaxation. Sit down at the table rather than eating on the run. Turn off cell phones and laptops, and try not to eat in front of the TV.

image Eating with purpose: One of the Power 9 is to live with purpose, and I believe it’s important to eat with purpose, too. Acknowledge that you are eating to nourish your body and brain to defeat anxiety. Be mindful about your food. Chew thoughtfully. Pay attention to flavor. Don’t feel guilt or regret about the food you eat. Enjoy every bite from the first to the last.

Looking beyond the Power 9, let’s meet two last patients of mine who needed to reset their eating practices before they could reap the benefits of an antianxiety diet.

THE DANGERS OF OVER-RESTRICTION

While I believe strongly in practicing concepts like hara hachi bu to avoid overeating, it’s also important to be aware that anxiety can push some people in the opposite direction, leading to overly restrictive eating practices that can leave them undernourished and overlap with other serious mental health concerns like eating disorders.

Annie was in her second year of college when she came to me with severe anxiety about her weight and appearance. Her anxious feelings were so powerful that she was avoiding all social situations because she was ashamed of how she looked. I was careful not to register surprise when she told me she had always struggled to lose weight, but it was very clear she wasn’t overweight. If anything, she looked significantly underweight. It seemed likely that Annie was suffering from body dysmorphic disorder, a psychiatric condition that was causing her to obsess about perceived flaws in her body that weren’t evident to anyone else.17

When we discussed what she ate, she assured me she ate very clean: fresh vegetables, chicken breast, and occasionally salmon, with no red meat and no added sugar. That sounded like a conventionally healthy diet, but as we talked further it became clear that she was eating small portions, fasting often, and rejecting many types of whole, unprocessed foods. Annie’s body dysmorphia was being compounded by a case of orthorexia nervosa, a condition in which people are obsessed with the quality of their food and overdo it on restrictive behaviors.18

Annie’s consultation put me on high alert. In my clinic, I am unable to work with patients who have active eating disorders—whether they are suffering from a highly restrictive anorexic-type disorder or binge eating. Patients with eating disorders need close monitoring of both their physical health (lab monitoring of hydration levels and hypoglycemia, for example) and their emotional health, as eating disorders can often lead to self-harm or suicide.19 People struggling with eating disorders often need psychiatric hospitalizations, and some may need a residential treatment program specializing in eating disorders.

After spending time with Annie and speaking with her about her underlying emotions surrounding food, I assessed that her restrictive eating was not yet advanced enough to pose an immediate threat to her physical health. And though she was deeply anxious, she was not at risk of harming herself. Instead of referring her to more intensive care, I decided to help her develop a personalized nutritional psychiatry treatment plan. My first step was bringing in two other team members: Alex, a nutrition coach, and an eating disorders counselor to help her work through the deeper issues that were surfacing through her food behaviors.

I started her on an SSRI to help manage her anxiety, and she spoke twice weekly to her counselor to improve and heal her relationship with food. Alex worked alongside Annie and me, helping to plan shopping trips where they would touch, feel, and explore more foods to add to her diet. Alex would ask Annie to write out a shopping list for the week, then we’d work together to gently encourage her to include more than the foods she was eating. We helped her understand the nutritious value of an expanded whole foods diet. We did not pay attention to weight or a scale. Noticing that her body dysmorphic disorder had kept her hiding under bulky clothes, when she was ready, we suggested she plan a shopping trip with a girlfriend to buy some new clothes and indulge in a hair and makeup session. Incrementally, she gained confidence and felt emotionally stronger until she was able to eat a wider range of foods, reach a healthy weight, and gain perspective on her body dysmorphia.

As I saw with Annie, orthorexia nervosa is recalcitrant and very often correlated with anxiety and low self-esteem,20 so it’s something I keep a close watch for in my patients as we redesign their diets toward healthier food. As important as it is to eat unprocessed, healthy food, it is equally important to maintain proper perspective on setting realistic goals and understanding that it’s possible to take an obsession with healthy eating too far. Even patients who don’t approach full-blown orthorexia nervosa can fall into the trap of letting the perfect be the enemy of the good, getting frustrated when they stray from their eating plan while traveling, celebrating, or participating in work functions. That’s exacerbated by the constant pressure and flood of (often incorrect) advice from social media. It’s always important to remember that your body is resilient and that no one meal is going to make or break your quest to escape anxiety. That’s why I recommend following overarching guidelines like the Six Pillars, rather than trying to account for each calorie; it’s far more important to change eating habits in a way that is sustainable for your lifestyle rather than chasing perfect adherence to a specific plan.

REDEFINING A DIFFICULT RELATIONSHIP WITH FOOD

For patients who come to me with a difficult relationship with food—whether a history of unsuccessful dieting for weight loss, a tendency toward binge eating, or over-restrictive eating like Annie—I often find that helping guide them to healthier foods and developing a personalized nutritional psychiatry meal plan is only one part of the process. There is also work to be done to reframe how they think about eating, opening the door to allow food to calm their minds.

Kayu was a Japanese woman who had immigrated to the United States in her early thirties. In Japan, she had eaten a traditional Japanese diet full of seafood and vegetables, which meshed very well with the Six Pillars, and she told me that she’d generally felt calm and focused in her work as a hairdresser. When she moved to the United States, her habits changed. She was nervous about integrating into American culture, so she ate what her friends ate, often binging on fried foods and pizza. She still ate Japanese food frequently but found herself gravitating toward Americanized Japanese food that she had never eaten in Japan, like fried chicken wings and tempura, all served with copious amounts of rice.

When she came to see me, Kayu was in such a heightened state that she was barely able to get a word out. She told me that her hands were shaking at work—not something anyone wants but particularly bad for a hairdresser—and that after a significant weight gain, she hardly recognized herself. Her stress and anxiety about her weight gain led her to seek out more comfort food. She realized her new eating patterns were unhealthy, but she felt like she couldn’t change them, since food had become the only thing that could calm her down. Most troublingly, she told me she had started to hate herself.

I empathized with Kayu and explained to her that she was not alone. Many immigrants to new countries go through a process called dietary acculturation, changing their diets dramatically in an attempt to fit into a new culture. A recent review looked at dietary acculturation in East Asian immigrants moving to Western countries, and the diet-related disorders that can arise, including increased risk of diabetes and cardiovascular disease.21

I recognized that Kayu’s biggest problem wasn’t knowing what to eat—she now knew that her traditional Japanese diet was intertwined with her mental health—it was that she needed to redefine her relationship with eating on a deeper level.

When I first started to talk to her about ways to change her relationship with food, she wasn’t interested. She told me that the body positivity movement irked her and that all she wanted was help losing weight and fixing her mood so that she could get her old life back. I explained that while I could certainly support her in building a new diet and managing her anxiety, the most important thing was that she put herself in a position to help herself. If her emotional eating continued, there was no way her antianxiety diet would be effective.

My discussion with Kayu was inspired by a philosophy called intuitive eating. While dieting can show results for weight loss and general health in the short term, studies have shown that food restriction has limited success over the long term. In fact, there is evidence that dieting not only leads to an increased risk of further weight gain five years later22 but also encourages your brain to associate food with reward and attention.23 Intuitive eating was first developed in 1995 by nutritionists Evelyn Tribole and Elyse Resch, who sought an alternative to this unhealthy and ineffective diet culture.

The central idea of intuitive eating is that rather than limiting your diet to certain types or amounts of food, you take cues from your body to determine what and how much you should eat. As we saw with the Blue Zones’ 80 Percent Rule, you focus on letting your body tell you when you are full, rather than eating habitually or reactively, overstuffing yourself just because food is available or because it makes you feel good in the moment. Intuitive eating and the ten principles that underpin it have been written about extensively in other books, so I won’t go into a great deal of detail here, but I certainly encourage you to explore this thoughtful and helpful approach to eating.

Intuitive eating can be particularly challenging for people who suffer from anxiety; as with Kayu, anxiety can feel debilitating, keeping you from doing the things you know you need to do to help yourself. But developing an intuitive eating practice can also be particularly powerful for anxious people. As we’ve seen in many different cases in this book, anxiety can lead you to overeat or undereat,24 distorting your feelings of hunger or fullness.25 Add on the kinds of social pressures that Kayu was feeling to fit into her new culture and friend group, and it can be challenging to approach food in a mindful and measured way. But that also means there is great potential for reframing how you think about eating and developing a new relationship that will help calm your anxiety no matter what kind of diet you choose to follow.

To get Kayu started, I introduced her to a simple plan I’ve developed called Dr. Uma’s Calm Diet. The idea is to help you understand that a diet is not meant to be a punitive tool. Diets are meant to provide frameworks for self-improvement based on your personal needs. Research demonstrates that shame, self-criticism, and perceptions of inferiority make you lose self-control and undermine the effectiveness of what you are trying to achieve by changing your eating habits.

Focus On:

image Self-love and respect. Knowing and honoring your needs is where self-love and respect begin. This is a pillar of helping yourself heal your anxiety.

image Self-attunement. Paying attention to body intelligence teaches you how to be in tune with your own body and brain, which can help you gauge the effects of different foods.

image Self-listening. Anxiety comes with different emotions for different people. Listening to your own triggers is key to helping you overcome your own specific brand of it.

image Self-direction. Being self-directed makes you feel empowered and in control of managing your anxiety by directing your self-love, self-attunement, and self-listening to lowering your anxiety.

image Self-improvement. As you work through the other steps, allow yourself to feel your improvement as you heal your anxiety.

Be Aware of:

image Perfectionism. Don’t try to be perfect, especially when it comes to how you eat and feel. Everyone is going to make mistakes and have bad days. Have grace with yourself.

image Criticism and judgment. Stepping back from being harsh to yourself and others will help you release and lower anxiety.

image Letting others lead you. One of the positive impacts of nutritional psychiatry is that it gives you autonomy over the initial steps you can take to reducing your anxiety. While it’s good to work with a trusted professional, don’t let the popular press or social media lead you.

image Self-hatred and criticism. Practicing mindfulness and soothing self-hatred will help relieve anxiety triggers.

image Putting your emotions before the whole you. Your anxiety is a part of you, but you need to understand that it does not define you. By following the nutritional and integrative principles in this book, you can lessen the burden of anxiety on your whole self.

As I walked Kayu through these steps toward reframing her relationship with eating, I explained to her that I was not asking her to love her weight gain or her anxiety, but to give herself permission to listen to what she already knew. She did not believe that eating a plate of deep-fried tempura or chicken wings was good for her on a regular basis. Of course, these foods were delicious, but she cared about more than deliciousness. She cared about allowing her brain and body to feel their best. But she had lost sight of those priorities as she had understandably let her desire to fit in override everything else. Rather than self-criticizing, or letting her emotions convince her that there was no way to change, I encouraged her to get back in tune with how she ate in Japan.

She took in what I was saying and became more enthusiastic about finding ways to get back on track. Our plan was simple: We took an inventory of which Japanese foods agreed with the Six Pillars and looked for ways she could integrate them back into her diet. We discussed principles like hara hachi bu, which helped make her feel more culturally grounded in her eating. She told me she had never been much of a cook growing up, but I told her the same was true for me—I had relatives who were expert cooks; I never learned to cook many of the dishes I grew up eating until I was studying later and living on my own. She made a point to ask her own relatives for recipes and cooking tips, as well as enrolling in a Japanese cooking class that was offered nearby. As she began to cook for herself more, she prioritized healthier options like sushi, steamed vegetables, and fresh salads, avoiding tempura and fast food.

With these changes—and without using any medication, which she wanted to avoid at all costs—Kayu was able to go back to cutting hair with a steady hand. In six months, she lost twenty pounds and became the version of herself she wanted to be.

THE BEST DIET IS THE ONE THAT WORKS FOR YOU

My years of clinical work have reinforced time and again that every person eats differently. All of us have different cultural backgrounds, different palates, different food priorities. Every one of our bodies and gut microbiomes reacts to food in different ways. It would be foolish to try to fit every single person into a single dietary template. In fact, I suspect this is a major reason diets don’t work for most people. How we eat is how we live, it’s not separate, so aligning our true values with the foods we eat is crucial to live our best lives.

Apart from the foods we choose to eat, some people hate to follow a regimented eating schedule with each meal planned weeks in advance. Others absolutely love the structure and knowing in advance what they are going to eat. Some have more self-control over their food choices than others. Some cook by feel, adding a pinch of this and a dash of that. Others enjoy getting out the food scale to weigh out portions down to the gram.

In this chapter, I hope I’ve impressed upon you that different ways of eating are perfectly fine, as long as you are following the Six Pillars to Calm Your Mind. By combining those principles with the basics of the best diets out there, and listening to your body through intuitive eating, you have the power to construct a revolutionary personalized plan to control your anxiety with food.