part0007

The discovery of the “second brain,” also known as the enteric nervous system, has confirmed our experience that the “gut” communicates with our first brain. This second “brain” controls the digestive system via a complex network of over 100 million nerves and chemicals that send messages to the central nervous system, and this “brain” allows us to feel in our “guts.” When we say: “I just feel in my gut that is right,” or “my gut is telling me no,” that sensation is the second brain communicating. Feeling and sensation are part of its function, and it is linked to our emotional lives and intuition. The majority of fibers in the vagus nerve carry messages from the digestive system to the brain. The feeling of “butterflies in the stomach” describes the physiological stress we experience in the gut. This “second brain” is a term coined by Gershon (1998). It controls the breakdown and absorption of foods, elimination of waste, and the rhythms of peristalsis that move food along the digestive tract. It takes food particles and transforms them into little chemical messengers that support our emotional and cognitive life. The revolution that has occurred is that we now know that it is this second brain that makes these little messengers, the neurotransmitters, and supports bacteria that help regulate brain function.

An important discovery of the last 30 years relevant to the second brain and mental health is the endocannabinoid (eCB) system. This system figures in mental health, nutrition, and especially, in pain and the addictions. Note the middle word root “canna” and you will note it is related to the word cannabis. This system was identified as functioning in the first and second brain when scientists first began to identify the parts of the brain that responded to cannabis, or marijuana. The eCB system is involved in all aspects of mental and physical health: the microbiome and gut permeability, the stress response, appetite, obesity and eating disorders, the experience of pain (McPartland, Guy, & Di Marzo, 2014), and the “bliss states.” The neurologist Russo (2004) proposes a concept called clinical endocannabinoid deficiency syndrome, which may contribute to migraine, fibromyalgia, irritable bowel syndrome, and psychological disorders. Knowledge of this system is also central to understanding why people with schizophrenia and posttraumatic stress disorder (PTSD) may use cannabis to self-medicate, and the ways in which medical cannabis represents a growing option for less toxic medical treatments for mental illness and chronic physical diseases.

Chronic stress is also connected to allostatic load, which refers to the cumulative effects of the “wear and tear” on well-being. Allostatic load is of special importance to the second brain because the social stressors of poverty and discrimination, as well as environmental toxins, affect the ability to metabolize food, especially glucose. For example, the stress of poverty is linked to the stress of malnutrition and poor-quality nutrition on child and adult development. These stressors also include less access to quality nutrition at a time when even greater needs are placed on the mind and body for nourishment. Environmental toxins in poor urban centers are linked to higher rates of diabetes, and environmental toxins in the food supply are associated with earlier puberty in girls, which has a domino effect on risk factors like depression and sexual abuse. Incorporating socioeconomic context and the complex interplay of ethnicity and stress on mental health and nutritional status is essential to the nutritional change model I discuss throughout this book in order address affordability and health disparities.

The first brain relies on the right mix of glucose and fat. If you do not consistently eat the correct combination of glucose and fats, you deprive the brain of its optimal fuel, frequently leading to hypoglycemia and ongoing cravings and hunger. Meals low in protein and fat and high in carbohydrates raise blood sugar, but they also drop sugar levels precipitously, sending the brain on a rollercoaster. These high glycemic meals impair satiety hormones and cause an increase in hunger hormones (Baum et al., 2006), which leads to overeating. These types of high-carbohydrate meals also result in fatigue. This pattern is common in people with mood lability, and they respond well to a diet low in carbs, high in animal and plant protein, and moderate in fat and vegetables. The “power lunch” refers to eating a lunch of protein and vegetables (no grains or alcohol) when negotiating an important contract or business exchange and gaining a mental edge by staying alert and awake without the sedating effects of grains and starchy carbohydrates.

In order for digestion to function smoothly, one needs to be relaxed when eating. There is a long-time association between stress and digestive upset. This is mediated by the autonomic nervous system (ANS). Under normal circumstances the parasympathetic mode of the ANS is the autopilot that “automatically” drives the overall function of the digestive system, from the release of digestive enzymes and juices to peristalsis and elimination. In mental health we have long observed the relationship between anxiety and digestive problems. We once believed that anxiety drove the digestive problems, and thus we teach relaxation exercises that are helpful. This makes sense, as the parasympathetic system, our relaxation response, needs to be “on” for digestion to occur smoothly. However, we now know that the effect of the gut, or the digestive system, on anxiety and emotions in general is bidirectional due to the vast network of chemical messengers, the neurotransmitters that are produced in the gut. Mindfulness exercises such as the one provided in Box 2.1 help clients engage their relaxation response and enhance their awareness.

Box 2.1

Exercise to Teach Clients: Chewing the Raisin

To enhance parasympathetic nervous system function and relaxation, I guide a client through a series of mindfulness exercises beginning in the office and ask the client to complete the others at home and to share with other family members. Begin by reading aloud, allowing enough time to reflect on each observation and sensation :

Hold a raisin and observe it as though you are the first person to ever touch a raisin and you are investigating for the first time. See the raisin in all of its detail; observe every part of it—the wrinkles, the way the light shines on it. Touch the raisin and explore the texture and sensation. Smell the raisin and inhale its aroma; take note of how this fragrance may stimulate your stomach or mouth. Gently and slowly place the raisin in your mouth and, before chewing, take time to notice how it feels on your tongue and any other sensations you notice. Prepare to chew the raisin by slowly finding out how to position it for chewing. Chew the raisin a couple of times and notice what happens when you do, really tasting it in all of its subtle complexities. Before swallowing, notice how the texture of the raisin changes as you chew it. When you are ready, think about swallowing the raisin and experience the intention of swallowing. Then swallow the raisin. Afterward, see if you can feel the raisin as it moves to your stomach. Observe how you feel after this exercise in mindful eating.

Neurotransmitters (NTs) are brain chemicals that communicate information throughout our brain and body. They relay signals between neurons. They affect mood, sleep, concentration, weight, carbohydrate cravings, and addictions, and they can contribute to depression, pain, anxiety, and insomnia when they are not in balance. Research continues to illuminate the ways that foods affect how NTs are made in the gut and how, in turn, this affects the brain and mind. Friendly bacteria play a role in the production of gamma-aminobutyric acid (GABA), the “antianxiety” NT illuminating the complex relationship between the brain and the gut. The gut and the brain regulate eating behavior and appetite by way of NTs. Dopamine and serotonin are the two primary neurotransmitters associated with the regulation of food intake (Bello & Hajnal, 2010; Capasso, Petrella, & Milano, 2010). For example, when people start selective serotonin reuptake inhibitors (SSRIs), or the serotonergic amino acid 5-HTP, they can become nauseated by the increase in serotonin levels in the gut. Stress impairs digestion, and poor digestion affects the neurochemicals that influence mood and well-being. Like the brain, the second brain uses over 30 NTs, and 95% of the serotonin in the body is located in the gut. High levels of serotonin are also linked with irritable bowel syndrome (Hadhazy, 2010).

Impaired digestion of protein means the amino acids are not available to the brain to support NT production, directly affecting mood, sleep, and cravings. The overuse of antibiotics, along with insufficient prebiotics in the diet to prepare the garden of the intestines to grow healthy gut microbiota, impairs the production of NTs and subsequently causes mood problems like depression and anxiety. Most antidepressants are believed to work by increasing the availability of specific neurotransmitters, but this theory is unproven; they often have side effects, lead to chemical imbalances, have limited efficacy (especially in mild to moderate depression), and become less effective over time. The theory of mood disorders as primarily based in NT imbalance is giving way to a more holistic understanding of multiple influences on mood and cognition of which NT function is only one. Indeed, the groundbreaking work by Kirsch et al. examined the role of the placebo effect on depression and suggested that there is no significant difference between antidepressant effect and placebo effect except in the severely depressed, and for the severely depressed it is “the relationship between initial severity and antidepressant efficacy [that] is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication” (2008, p. 266).

Box 2.2

Exercise: Mindful Eating

Observe yourself chewing. Pay attention to the texture and flavors of the food, the smells, and the position of the food on the plate. Embrace the whole of the sensory experience. The production of saliva breaks down the food and tends to enhance the experience of texture and flavors on different parts of the tongue. Chew every bite until it is liquid in the mouth, allowing the food to travel down the throat and into the belly.

Food is made up of carbohydrates, proteins, fats, water, vitamins, and minerals. Carbohydrates are sugars, starches, and fibers, either simple (as in fruits, vegetables, and sugars) or complex (as in whole grains, starchy vegetables, and beans). The purpose of digestion is to break down these foods into smaller particles so they can be absorbed in the bloodstream and used throughout the body. Digestion releases the nutrients in food so that the body utilizes them. This process takes place in the gastrointestinal tract. Carbohydrates break down into glucose, which supports brain function; proteins, from meat, beans, eggs. and dairy products, are broken down into smaller molecules called amino acids, which are the building blocks of neurotransmitters that also support brain function. Fats provide energy for the body and the brain, which is mostly made up of fats.

Traditional fats such as butter, coconut, tallow, and suet (from cows and lambs); fat from ducks, geese, chickens, and turkeys; and lard from pigs are all “saturated” fats. They are “traditional dietary fats” since they have been used in cooking for thousands of years before the development of commercially created saturated fats such as shortening and margarine. Natural saturated fats are normally solid at room temperature. This type of fat includes different fatty acids such as butyric acid (found in butter), lauric acid (found in coconut oil and palm oil), myristic acid (found in dairy products), palmitic acid (found in meat and palm oil), and stearic acid (found in meat and cocoa butter). These fatty acids exhibit antibacterial, antifungal, and anti-inflammatory properties that help to protect the body.

It is a medical myth that saturated fats are dangerous. Saturated animal fats (from pasture-fed livestock) provide fat-soluble vitamins A, D, and K2. Eating saturated fats has been shown to lower Lp(a), which is an indicator of heart disease risk. Saturated fats stimulate prostaglandin 3, which is a pain-reducing anti-inflammatory, and exert a protective anti-inflammatory effect mediated via the vagus nerve and cholinergic anti-inflammatory pathways through the activation of cholecystokinin and nicotinic acid receptors (Luyer et al., 2005). If you do not eat enough fats, the body can make saturated fats out of refined carbohydrates. It is this process of high carbohydrates converting to triglycerides that raises triglycerides in the body (not saturated fat consumption). This process is associated with depression and vital exhaustion (Igna, Julkunen, & Vanhanen, 2011).

A commercially created form of fat that does not occur in nature is called “trans fat.” Trans fats are a contaminant by-product of commercial hydrogenation of vegetable oils. The process of hydrogenation renders liquid vegetable oils as creamy, spreadable substances that are used to make margarines and baking shortenings, but the high temperature needed to produce the products breaks down the vegetable fats and creates trans fats. Preparing foods with hydrogenated oils may result in food containing high levels of trans fats.

Changing diets to include healthy fats for brain function is one positive behavior that is easy to accomplish. The second behavior required is to eliminate the use of unhealthy fats or trans fatty acids. The scientific evidence is strong that trans fats consumed in even limited amounts interfere with the delta-6 desaturase enzyme and other enzymes necessary for the conversion of Omega-3 and Omega-6 to essential fatty acids (to sustain life) necessary for cellular and organ health (Enig, 2000). Essential fatty acids (EFAs) are those fats that are required for body health, cannot be synthesized by the body, and must be obtained from dietary sources.

Polyunsaturated fats (PUFAs) include soybean oil, corn oil, sunflower oil, and fatty fish such as salmon, tuna, herring, mackerel, and sardines. These oils containing PUFAs are normally liquid at room temperature and solid when cooled. Nuts, seeds, fish, and leafy greens also contain polyunsaturated fats. There are two types of essential fatty acids (Omega-3 and Omega-6) that may be derived from polyunsaturated fats. Omega-9 is another, but it is a nonessential fatty acid since the body can convert Omega-3 and Omega-6 to produce Omega-9. It is a valuable fatty acid obtained from avocados and avocado oil. Two absolutely essential Omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic (DHA), must be obtained from dietary sources such as fatty fish and nuts. They are the building blocks for hormones that control immune function, blood clotting, and cell growth as well as components of cell membranes.

Margarine and shortening also contain hydrogenated polyunsaturated vegetable oils, which contain trans-fatty acids (see earlier). Avoid any products with ingredients preceded by “hydrogenated” or “partially hydrogenated.” Polyunsaturated oils are also known to cause sterility and impaired immune function. Notably, liver damage, impaired reproductive health, damage to the lungs, digestive disorders, learning delays, weight gain, and neurological problems are frequently associated with polyunsaturated oil consumption.

Monounsaturated fats (MUFAs) are obtained from vegetable sources such as avocado and avocado oil, olives and olive oil, and tree nuts. MUFAs include palmitoleic acid and oleic acid—oils that are normally liquid at room temperature and solid or semisolid when cold. Olive oil is best eaten raw and not used in cooking. It is well known for its medicinal benefits on the gallbladder and for its rich source of chlorophyll, which detoxifies the intestinal tract. Other healthy foods containing MUFAs are full-fat dairy products and red meat from lamb, beef, and wildlife, such as deer, elk, moose, and bear.

Introducing good-quality fats into the diet as both foods and supplements and eliminating poor-quality fats is a primary way to begin a nutritional program of recovery. Essential fatty acids (EFAs) are fats that are essential and must be obtained through foods. They are essential to health and recovery. The Inuit located in or near the Artic Circle, whose diet consists of up to 70% animal fat and protein, showed few signs of mental illness or heart disease prior to the introduction of nonlocal foods to their diet. The primary essential fatty acids are Omega-3 (linolenic acid), Omega-6 (linoleic acid), and arachidonic acid (AA). The brain is made up of 60% fat, called docosahexaenoic acid (DHA). A variety of fish oils from krill, sardines, salmon, and cod can easily be integrated into the diet. A complement of fats from animals, vegetables, nuts, and seeds extracted via a “cold process” should be integrated into a daily diet for health with all other oils, along with the much-maligned egg, rich in choline, for the brain and memory.

Phospholipids are a special type of fat that comprise neuron membranes and support communication between neurons. Think of the layers in lasagna; without the various fillings, lasagna would not taste like much or even do much since the pasta needs the filling to really add the “zest.” Such are phospholipids to brain cells. Significant research demonstrates that problems in phospholipid metabolism contribute to major depression, schizophrenia, and bipolar disorder (Eggers, 2012; Horrobin, 2001; Leyse-Wallace, 2008), suggesting a role for both testing and supplementation of eicosapentaenoic acid (EPA) as well as phosphatidyl serine and phosphatidylcholine in these disorders in particular (Eggers, 2012).

Carbohydrates are the second category of food nutrients. Carbohydrates function primarily to regulate fat metabolism and thus generate energy for daily living. Protein, fats, and carbohydrates all work together to support the engine of the brain—sugar, glucose, amino acids, and fats, which lubricate and ease connection at the synapses. Too much or too little of different kinds of nutrients creates imbalances that have a negative effect on mood and cognitive function. For example, too much glucose from a diet high in refined carbohydrates is now considered a risk factor for dementia—now referred to as type 3 diabetes. An annual HbA1c test, as explained in Box 2.3, can provide information on Alzheimer’s risk due to blood glucose levels.

Box 2.3

Blood Glucose and Alzheimer’s Risk

The HbA1c test assesses an average blood glucose level over the previous 3 to 4 months. Because HbA1c is a glycation of the hemoglobin protein, the test is also a marker of protein glycation. When HbA1c levels are elevated, as they are in diabetes, it indicates that proteins including hemoglobin are being glycated. When proteins are glycated, inflammatory cytokines and free radical production is increased, leading to oxidative stress, which is a significant risk factor for Alzheimer’s and brain shrinkage.

Carbohydrates are made up of sugar molecules and are either simple or complex. A single sugar molecule is known as a simple sugar, whereas many sugar molecules bonded together in a chain is called a complex carbohydrate, or starch. Sugar is the simplest form of carbohydrate and is found in fruit, vegetables, dairy products, and refined sugar. Complex carbohydrates are either starch or fiber. Starchy vegetables, such as carrots, potatoes, and peas, and grains, such as wheat, rice, barley, and oats, are sources of starch. Starches can also be from refined foods, such as cornstarch, chips, and certain dessert foods. Complex carbohydrates provide necessary fiber in the diet. Grains are a particular type of carbohydrate. Most people will do well on fruits and vegetables, and some will do well with grains, though some clinicians, such as the neurologist Perlmutter (2014), suggest that grains should be avoided altogether because they are detrimental to cognitive function in particular.

Proteins are the third category of nutrients essential to both mental and physical health. They fuel every function of living cells. Proteins are derived from either animal or plant sources, and they must be broken down by digestion into amino acids in order to be used by the body. Animal proteins such as whey, eggs, beef, casein, and fish differ from plant proteins such as soy, pea, hemp, and rice in many ways, including cholesterol and saturated fat levels, digestion rates, allergens, and their amino acid profiles.

Everyone has a different need for protein relative to her or his individual biochemistry. Some need more protein than others. However, during times of stress they are more essential; they support growth and repair in the body, which tends to break down under stress. A broad approach to calculating protein needs is to identify the optimal daily ratio of protein that is about 0.5 grams of protein for every pound of lean (muscle) body mass. A person with 20% body fat mass has 80% lean mass. So for someone who weighs 200 pounds, the lean mass is 160 pounds. To determine the protein requirement, divide 160 by 2.2, which converts pounds to kilograms, resulting in 72.7 grams of protein. Protein requirements increase if one is doing vigorous exercise, and women generally need less protein. People who eat the standard American diet tend to overconsume poor-quality protein at nearly twice the amount that is necessary, while vegetarians tend to underconsume proteins. Both approaches are problematic for mental health. Protein from animal foods have better amino acid profiles than plant proteins, meaning they have higher amounts and proportions of the essential amino acids. Another challenge in vegetarian diets is the failure to consistently combine proteins that have complete amino acids, and this leads to deficits in NT synthesis.

It is important to address both quality and quantity when determining protein requirements. Eggs are a perfect protein and provide about 5 grams of protein per egg, the equivalent of a handful of nuts or seeds. Milk and yogurt provide about 10 grams of protein per cup (milk products are best eaten raw and unpasteurized). Beans, cottage cheese, and tofu each provide about 15 grams of protein per cup. Meat, chicken, and fish provide about 25 grams of protein per 3- to 4-ounce serving.

Proteins along with vegetables are also part of the satiety complex. Proteins such as nuts, seeds, and whey, along with greens, cruciferous vegetables, and root vegetables, all promote satiety (Baum et al., 2006), which is important especially when making dietary changes and in hypoglycemia, compulsive and night eating disorder, and bulimia. Raw almonds are an ideal food to eat as a snack or at the start of a meal. This may underlie the wisdom of Ayurvedic medicine that suggests eating 10 raw almonds a day for brain health and relaxation. I can think of no simpler daily habit to support brain health and a relaxed mood .

Insufficient protein intake is not always the problem; rather it is often the inadequate digestion of proteins that causes protein deficiency. Before protein is available for the body to use, it must be broken down into more digestible forms. Insufficient hydrochloric acid is one cause of poor protein digestion, as hydrochloric acid is needed to break protein down into its constituent parts. Without enough hydrochloric acid, proteins are not fully digested, nutrient absorption is reduced, and satiety signals to the brain are impaired. Antacid use is another cause.

Protein deficiency is most likely to occur in people on a strict vegetarian diet who do not consume adequate amounts of plant proteins, or who do not combine them to obtain the complement of all amino acids. Bulimia, fruitarian diets, diets high in refined carbohydrates, and alcoholic liver damage also contribute to protein insufficiency, which in turn affects amino acid and NT levels. Symptoms of protein deficiency include a lack of mental focus, emotional instability, impaired immune function, fatigue, hair loss, and slow wound healing.

The gastrointestinal (GI) tract is a long system of hollow organs that are joined together, creating an unbroken tube that begins at the mouth and ends at the anus. These organs include the mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus. The liver, gallbladder, and pancreas are additional, solid organs that play essential roles in the digestion of food. Food enters the mouth, is chewed and reduced by saliva, which adds a lubricating antibacterial fluid that helps food travel down the esophagus. From there it travels into the stomach, where powerful stomach acids break it down so it can be further absorbed. The liver and gallbladder digest fats, and when the foods are washed with pancreatic juices rich in enzymes, the food is called chyme. If foods are not fully broken down, they can ferment in the digestive tract. Imagine filling a pot with meat and vegetables and putting it on the stove but neglecting to light the fire to cook it. What would happen? Over a few hours into days it would start to ferment and sour, bubble and smell. This happens in the belly of someone who is not digesting her or his food. The bubbles result from gas, and the sour comes out in bad breath and flatulence .

Digestive enzymes help break down food, much like a fire on the stove prepares food to be eaten. Enzymes break down food into nutrients that the body can absorb. The salivary glands, stomach, pancreas, and the intestines all secrete digestive enzymes. Digestive enzymes are also found mainly in raw foods, and they are especially rich in papaya and pineapple, making some raw foods de rigueur of every diet. Low and deficient enzyme levels may be responsible for food intolerances, most commonly to gluten, dairy, legumes, fruits, and vegetables, causing conditions like eczema and celiac disease.

Stress can also affect digestion at the esophageal sphincter, where like a drawbridge it may open when it is supposed to close or close when it is supposed to open. Sometimes it relaxes too much and closes on part of the stomach, pushing the stomach up. This is called a hiatal hernia. When the sphincter does not close effectively, this allows stomach acid to rise into the lower esophagus, causing acid reflux or gastroesophageal reflux disease (GERD). There are high rates of GERD in people with PTSD, suggesting the link between anxiety and GERD.

Under stress, one eats too rapidly and swallows food whole; under stress, the acids and enzymes required to break down food cannot do their job. With food undigested in the belly, pains and gases develop, perhaps medications are used to quell the discomfort, nutrients are malabsorbed, and organs including the brain are malnourished. Eating food slowly allows for the initial breakdown of starches. Starchy carbohydrates require the enzyme amylase. The salivary glands store amylase and secrete it to aid in the digestion of sugars. There are two kinds of saliva—a thin, watery saliva that moistens the mouth and the food, and a thick, mucous saliva that lubricates the food and helps form it into a ball, called a bolus, which can then be swallowed .

The stomach receives the fuel, which should already be predigested by the salivary enzymes. The stomach acid then digests proteins. Proteins are large food molecules that need to be broken down by proteolytic enzymes into their smaller components called amino acids, which in turn are the building blocks of neurotransmitters. Proteins are either animal based (meat, seafood, eggs, dairy) or plant based (beans, nuts, seeds). The muscle of the stomach churns the food up and mixes it with the gastric juices. This is what we call the digestive fire. Without stomach acid, food would not be digested. This is another place where stress can interrupt digestion.

Pepsin is secreted by the stomach and begins the process of protein digestion, and the pancreas secretes trypsin, chymotrypsin, and proteases into the small intestines; the pancreas also secretes proteases. Proteolytic enzymes, also secreted by the pancreas into the small intestines, break down proteins that were not fully digested by the stomach. Proteins and fats are not absorbed when there is a lack of pancreatic enzymes, and this can lead to nutritional deficiencies.

Insufficient gastric acid secretion is known as hypochlorhydria. When food is not broken down because of hypochlorhydria, it moves into the small intestine and colon undigested and the body is not able to make use of it. Absent the ability to break down proteins, the second brain cannot make the NTs such as tyrosine and tryptophan required for healthy neurotransmitter production for the first brain. This condition frequently results in anxiety, depression, pain, chronic indigestion, food allergies, and asthma.

Hydrochloric acid (HCl) is produced by the stomach and contains enzymes that help break down proteins. Gastric acid production decreases with age, and a lack of HCl can cause other digestive problems like small intestinal bacterial overgrowth (SIBO) because of elevated pH levels. SIBO inhibits nutrient absorption and assimilation of the B vitamins folate, B6, and B12, resulting in major depression (Logan & Katzman, 2005), and low HCl in general is associated with increased levels of anxiety. It now becomes ever more clear why, over time, poor digestion means poor mental (and physical) health.

While the stomach is adding fire to the mix, the gallbladder is emulsifying the fats needed to elevate mood and decrease stress as well as to maintain artery health and reduce inflammation. The brain is mostly fat in the form of docosahexaenoic acid, and neurons require fats to function smoothly, just like a car needs lubrication. Without access to good fats or the ability to use these fats, the brain does not get the fuel it requires. If the gallbladder is not functioning well, dietary fats or fish oil supplements will be less effective because those nutrients cannot be emulsified and assimilated.

Normally, the liver and gallbladder work together to emulsify fat, just like dish soap breaks down the grease in a frying pan. Bile, which is made up of bile salts, cholesterol esters, and lecithin, emulsifies the fats and separates them into smaller fat globules so they can pass through the digestive system. Contrary to conventional belief that one must follow a low-fat diet with gallbladder problems, a very low-fat diet can cause the gallbladder’s “muscle motor” to slow down. This special muscle pushes out bile into the duodenum. When the muscle fails, it leads to a buildup of sludge like a stagnant pond that backs up. Good-quality oils, in particular a regular dose of olive oil mixed with lemon juice, avoids this immobility.

The word bile is derived from the Latin bilis , meaning anger or displeasure. Traditional Chinese medicine suggests the emotion of anger derives from a congested gallbladder and liver. Sayings like “That takes gall” or “I got my bile up” refer to the longheld belief that a congested liver/gallbladder results in anger and rage. Junk food, refined foods, trans fatty acids, and alcohol abuse contribute to chronic gallbladder congestion, low bile output, gravel, and gallstones. Other symptoms of gallbladder problems include burping, flatulence, a feeling of heaviness after a meal, shoulder pain, pain under the ribs on the right side or in the back directly behind the diaphragm, and nausea. Awakening with bloodshot eyes after a heavy meal the night before is another sign of gallbladder distress.

Medical practitioners in the United States remove over 750,000 gallbladders annually. Treatable gallbladder disease is at epidemic levels and is at the heart of poor mental health. Poor liver and gallbladder function worsen stress and depression. Some medical researchers suggest that there is a genetic cause for gallbladder disease (and diabetes) within certain cultural groups, especially in American Indians and peoples south of the US border. But there was virtually no gallbladder disease among these peoples prior to the arrival of the “modern” standard American diet. Removal of the gallbladder only aggravates health problems by decreasing the capacity to digest foods and fats. Removing the gallbladder surgically is like throwing out the garbage pail instead of simply emptying it. Surgery for gallbladder conditions should always be avoided except if an individual’s life is in immediate danger.

Most cholesterol is made in the liver. Sufficient cholesterol is essential for mental health. Despite the popularized view that cholesterol is dangerous, I want to emphasize that cholesterol is necessary for proper brain and nervous system function, and it is an important part of our ability to use serotonin, thereby preventing depression. People have differing needs for cholesterol; some do well with total cholesterol at 240 and others do well at 180. For those whose cholesterol dips too low for their individual needs, anxiety may follow.

Cholesterol is frequently condemned as a major cause of heart disease, but this is untrue. Efforts to reduce cholesterol with diets extremely low in fat and with medications contributes to significant mental distress, including anxiety, muscle pain, and suicide attempts (Perez-Rodriguez et al., 2008). Statin drugs used to lower cholesterol, such as Lipitor, Pravacol, Mevacor, and Zocor, are known to cause significant side effects such as muscle wasting and weakness, heart failure, depression, cancer, and cognitive impairment. Numerous studies have demonstrated that there is no significant relationship between cholesterol intake and heart disease (McNamara, 2014) but rather that people with cholesterol below 200 consistently show lower cognitive functional capacity (Elias, Elias, D’Agostino, Sullivan, & Wolf, 2005). A recent study of 50,000 individuals in Norway found that women with total cholesterol over 200 mg/dL lived longer than those with lower cholesterol (Petursson, Sigurdsson, Bengtsson, Nilsen, & Getz, 2012). People with elevated homocysteine levels have a greater risk of cognitive decline. Low plasma cholesterol (160 mg/dL) may serve as a biological marker of suicidality (Vuksan-

usa, Marcinko, Na

, & Jakovljeci

, 2009) and is linked with depression and increased mortality from accidents and homicides (Leyse-Wallace, 2008).

Cholesterol is a precursor of hormones, the raw material for producing certain fat-soluble vitamins like vitamin D. Cholesterol is the liquid “band-aid” that is released to scout out and repair arterial inflammation frequently caused by trans fats, stress, manufactured foods, contamination from waste, and environmental toxins. The key to managing cholesterol levels is to reduce inflammation, not cholesterol per se. Hormones made by cholesterol are important for blood sugar regulation, mineral metabolism, and our ability to tolerate stress.

Restricting cholesterol in the diet reduces the amount of Omega-3 in the diet, and concurrently DHA levels are reduced. This affects the ratio of Omega-3’s to Omega-6’s, increasing Omega-6 levels, altering the membranes of brain tissues and increasing one’s susceptibility to depression. In fact, in populations where Omega-3 intake is higher, the rates of depression are lower. Indeed, as I explore in Chapter 4 , low cholesterol is implicated in autism spectrum disorders.

Cholesterol is also essential for the synthesis of vitamin D, the fat-soluble vitamin. Low levels of vitamin D are associated with chronic pain and depression (Vasquez, Manso, & Cannell, 2004). Cholesterol is also the precursor of glucocorticoids (necessary for blood sugar regulation), mineralocorticoids (essential for mineral balance), ligament strength, blood pressure regulation, and sex hormones. Cholesterol is also the foundation for pregnenolone, which serves as the predecessor to virtually all other steroid hormones (including progesterone, cortisol, aldosterone, and testosterone). Pregnenolone is synthesized in the central nervous system as well as the adrenal glands. Low levels are associated with depression, anxiety, and pain (Marx, 2009). Pregnenolone is also metabolized to allopregnenolone, an anxiolytic. It increases acetylcholine release, which is central to memory and focus and enhances the creation of neurons. Lowering cholesterol decreases the capacity to make pregnenolone. Pregnenolone is also an important ingredient of several brain nutrient support compounds required for brain recovery that I discuss in the next chapter.

The pancreas is an organ that functions as an exocrine and an endocrine gland. The pancreatic juices consist of proteolytic (protein-digesting) enzymes that help to further break down starches, fats, and proteins. As an exocrine gland, the pancreas secretes digestive enzymes into the small intestine that help to break down the chyme that has just left the stomach and entered the duodenum. The pancreatic enzymes secreted into the duodenum include the proteases trypsinogen and chymotrypsinogen, as well as amylase and lipase. Lipase is an enzyme that breaks down fats and is also secreted by the salivary glands. This important enzyme converts fats into compounds useful to the body such as fatty acids and glycerol. As an endocrine gland, the pancreas produces and releases hormones into the bloodstream that help regulate glucose metabolism and blood glucose levels. These hormones include insulin, which lowers blood sugar, and glucagon, which raises blood sugar.

Box 2.4

Proteolytic Enzymes Reduce Inflammation and Pain

Proteolytic enzymes serve two vital mental health functions:

1. When taken with food, these inexpensive enzymes help to digest food protein and they help to mediate food allergies. Protein-digesting enzymes produced by the pancreas can be further supported by supplementation.

2. When taken on an empty stomach, they “digest” inflammatory cells/proteins and improve immune function, reduce pain, inhibit the formation of fibrin in damaged tissues, and increase circulation to inflamed areas.

Food and supplement sources for these anti-inflammatories are papain (from green papaya), bromelain (from unripe pineapple), and serratiopeptidase (from the silkworm) .

After food has digested in the stomach, it is released into the small intestine. The small intestine works by peristalsis, the involuntary, undulating, wave-like movements of a muscle that moves food along through the intestines by contracting and relaxing. Under stress, these natural peristaltic rhythms can be disrupted and stop all together, like jamming on the car brakes and backing everything up, or by accelerating and increasing wave action and dumping waste too quickly. Either stress effect leads to discomfort. The small intestines also secrete digestive juices and enzymes so that foods, water, and minerals can be absorbed by the small intestine and passed into the bloodstream, where they are processed further and utilized by the body. It is here that fatty acids and vitamins are absorbed by the lymphatic system, and simple sugars, amino acids, glycerol, some vitamins, and salt are brought to the liver. The essential role of nutrition and intestinal health to mental health is described in Jill’s story in Box 2.5.

Box 2.5

Jill’s Story

Jill was an accomplished, middle-aged musician who presented with chronic anxious depression, adult acne, and chronic colitis that at times interfered with her work. She was taking antianxiety medication and also medication for colitis. Her diet was very limited because she did not digest food well. She ate no fruits and no raw vegetables and ate a lot of toast and butter and chocolate milk. Her medical history revealed the use of antibiotics as a child, missed school days due to stomachaches, difficulty gaining weight, and acne. She had been tested for celiac disease, but those findings were negative. I referred her to a local naturopathic physician with the request to conduct more extensive testing that analyzed blood, saliva, and feces for food sensitivities to dairy and gluten, gut bacterial levels, and pancreatic enzyme levels. Testing showed there was indeed gluten and dairy intolerance, along with very low levels of digestive enzymes and harmful intestinal bacteria, Clostridium difficile. The naturopath and I consulted and agreed upon a nutritional therapy course of action. We agreed that Jill would benefit from high-dose probiotic supplementation, but if that did not overtake the C. difficile, she suggested a fecal transplant.

Jill eliminated gluten and cow’s milk dairy immediately and began making simple meat and chicken broths. After a week she added some root vegetables and leafy greens to the broth and strained them so she could absorb the nutrients, but she still had reduced fiber. We supplemented her diet with high-dose probiotics because antibiotics would only exacerbate her gut imbalance. However, by eliminating gluten and casein and by introducing probiotic supplementation and bone and mineral broths rich in gut-soothing gelatin, she experienced improvement in 6 weeks. Jill was able to eliminate colitis medication, and at 8 weeks her anxiety decreased and she was able to wean off of all her medications. At 12 weeks her acne, often a symptom of milk sensitivity, had virtually cleared. We continued our work together slowly and included small amounts of raw foods by 6 months. Jill did not miss any more days at work due to digestive problems, and she felt restored and was much happier.

The intestine, and indeed the whole digestive tract, has come to be known as the microbiome . It is like your neighborhood community with people of all kinds: some friendly and some too noisy. Like your neighborhood, your microbiome is a community of a variety of microorganisms, some friendly and others not. A healthy neighborhood predominates with friendly people who cooperate and support each other and effectively manages the troublemakers. So it is with a healthy microbiome: It can tolerate some dissention but too much leads to illness that, if not addressed, can be damaging to the whole neighborhood (digestive system) and then affect the surrounding communities (brain, mental health). Furthermore, bacteria within the gut are manipulative (Alcock, Maley, & Aktipis, 2014) and both influence choices of food based on their needs, but in turn they can also be manipulated by our choice of foods.

Sometimes the bacteria are referred to as flora or microflora; the current term of reference is microbiota and the gut garden as a whole is called the microbiome , referencing the garden of living microorganisms that influence the whole organism. This microbiome is where the “gut-brain” connection plays on its seesaws, back and forth they communicate, feeding the neighborhood, including the first brain. Healthy intestinal bacteria populate the microbiome “garden” and when in abundance, keep levels of unhealthy bacteria from overpopulating. Healthy bacteria support the secretion and proliferation of neurotransmitters like GABA. Many GABA receptors are located in the stomach and esophagus. Healthy bacteria that populate the gut are essential for stress regulation and GABA, which leads to the reduction of anxiety (Bercik et al., 2011; Bravo et al., 2011).

The primary functions of the gastrointestinal tract are digestion and absorption of nutrients. Among the primary purpose of the intestines is to serve as the gatekeeper, a barrier mechanism to keep toxins and proteins out of the bloodstream that do not belong and to allow in those that do. Think of the drain in the kitchen sink. The finer the mesh, the more waste it collects, and the less problematic waste goes down the drain. The larger the mesh, the more particles get through and cause problems because they should not have breached the drain. Hence, the concept of “leaky gut” or intestinal permeability refers to when toxins and allergens breach this barrier.

Excess permeability allows molecules such as certain proteins from foods or toxins to enter the bloodstream, which contributes to allergies, autoimmune disorders, and inflammation. These toxins then travel to the brain and cross over a permeable blood-brain barrier. The blood-brain barrier is designed to protect the brain from unwanted substances and to allow those beneficial substances in that it requires. The blood-brain barrier is like the intestinal barrier subject to permeability that exposes it to toxins.

Intestinal permeability is an important problem that is common in all mental illness categories. One of the main reasons gluten and casein intolerance contributes to mental illness, including neurodevelopmental illnesses, is because it increases intestinal permeability (Herbert & Buckley, 2013; Pedersen, Parlar, Kvist, Whiteley, & Shattock, 2014; Whiteley, 2014; Whiteley et al., 2013). The gluten protein called gliadin triggers zonulin, a protein that increases the permeability between cells of the wall of the digestive tract, which leads to system-wide inflammation causing neurological, autoimmune, and mental health problems (Fasano, 2011).

In addition to zonulin and gluten gliadins, intestinal permeability is increased by a variety of factors, including low dietary fiber intake, excess of harmful microbiota, alcohol, age, Crohn’s disease, cystic fibrosis, rheumatoid arthritis, ankylosing spondylitis, atopic eczema, HIV, and certain medications, especially NSAIDS and antibiotics. Because autoimmune disease is linked to higher rates of mental illness, and increased intestinal permeability is widely considered to contribute to autoimmune disease, patients with autoimmune disease should be screened for depression and then treatment should focus on improving intestinal permeability .

Stress also increases the intestinal permeability; it can lead to release of mast cells associated with allergic immune response and the release of inflammatory cytokines, which negatively affect GI function (Konturek, Brzozowski, & Konturek, 2011). Following gastric bypass surgery people frequently develop immune-related arthritis, due to the production of antigens by the intestinal bacteria, which then move into the bloodstream. This likely explains why short fasting periods (Sundqvist et al., 1982) and even antibiotic therapies followed by restoration of healthy flora benefit people with rheumatoid arthritis who suffer from high rates of depression.

Also associated with excess permeability is SIBO, which occurs when large numbers of bacteria grow in the small intestine, and cause symptoms similar to inflammatory bowel syndrome. It can occur in response to chronic use of nonsteroidal anti-inflammatory drugs (NSAIDS) (Muraki et al., 2014) and proton pump inhibitors. Herbal medicines have proved to be as effective as antibiotics in treatment (Chedid et al., 2014). Among the most effective natural antibiotic is oil of oregano.

Stress and nutritionally related digestive problems can also affect the end of the alimentary canal, at the rectum and anus. For example, if fecal matter does not have enough fluid or fiber, it can lead to constipation and hemorrhoids. There is a significant association in children and adults between lower bowel function problems like hemorrhoids, constipation, and diarrhea and a history of sexual and physical abuse (Imhoff, Liwanag, & Varma, 2012; Rajindrajith et al., 2014). The combination of trauma treatment alongside nutrition is essential for improvement. This may include increased fiber and improving digestion through stress reduction, mindful eating, and belly self-massage (Korn, 2013).

Fiber intake is essential to a healthy colon and to mental health. There are digestible and nondigestible forms of fiber. The fiber sources that are indigestible carbohydrates are found in natural plant foods such as leafy green vegetables, fruits, legumes, nuts, and grains. Fiber has no calories or food energy, and yet it is a crucial component of a healthy diet. It passes through the digestive tract undigested, but in the process it sweeps up the debris along the colon walls and adds content to the digested food. Each day, women and men should obtain at least 25 grams and 38 grams of fiber, respectively. Fiber also causes the microbes in the gut to release a waste product called acetate, a short-chain fatty acid (Frost et al., 2014). Acetate goes to the hypothalamus and sends signals to stop eating, which then suppresses the appetite.

There are two types of fiber: soluble and insoluble. Soluble fiber slows down digestion by absorbing water and forming a gel in the digestive tract. It increases the feeling of fullness, and it slows down the rate at which the stomach empties, which also slows down the absorption of glucose, making it essential in the diets of people with diabetes. Soluble fiber is found in foods like oat bran, nuts, beans, lentils, psyllium husk, peas, chia seeds, barley, and some fruits and vegetables. In contrast, insoluble fiber does not dissolve in water, but rather it absorbs water and puffs up like a sponge, passing through the digestive tract and helping to push materials through. In this way it helps prevent constipation by providing a laxative effect. Insoluble fiber is found in wheat bran, corn, whole grains, oat bran, seeds and nuts, brown rice, flaxseed, and the skins of many fruits and vegetables.

Prebiotics set the stage in the colonic “garden” so probiotics or microbiota can flourish and not allow the harmful bacteria to propagate, much like healthy soil allows seeds to develop into fruit and be resistant to the effects of “pests.” Prebiotics are soluble indigestible dietary fibers that support the beneficial gut microbiota (bacteria) that live in the colon. Prebiotics include raw and cooked onions, garlic, Jerusalem artichokes, leeks, asparagus, wheat, beans, bananas, agave and dandelion, and chicory root, often found in coffee substitutes.

Chia is an example of an exceptional prebiotic as it has a mix of both soluble and insoluble fiber and has the added benefit of being rich in Omega-3 fatty acids. Traditional dietary practices include drinking a glass of water each morning in which chia or flax has been soaked, thus providing fatty acids and fiber. While juicing has many benefits, its main detraction if done to the exclusion of eating whole fruits and vegetables is that it removes most of the fiber from foods .

Probiotics are beneficial live microorganisms that colonize the intestines, maintaining a balance of the beneficial gut microbiota (bacteria). There are 400–500 different kinds of healthy microbiota that inhabit the gut. They promote a healthy digestive system; prevent infections, diarrhea, and inflammation; and improve immune health. They also produce nutrients, such as vitamin K, B vitamins, some short-chain fatty acids like lactic acid, and folate. Preliminary research on the oral administration of GABA derived from Lactobacillus hilgardii fermentation has been shown to reduce anxiety (Bested, Logan, & Selhub, 2013).

Probiotics are also called “psychobiotics,” referring to “a live organism that, when ingested in adequate amounts, produces a health benefit in patients suffering from psychiatric illness” (Dinan, Stanton, & Cryan, 2013, p. 720). These bacteria produce both GABA and serotonin and have been shown to reduce stress and decrease anxiety. Maintaining healthy bacterial levels in the gut supports NT activity in brain health. Early-life stress sensitizes specific gut microbiota to later life stress exposure. One study showed that lactobacillus, found in the traditional Korean food kimchi, increased hippocampal brain-derived neurotrophic factor (BDNF), a protein in the brain involved with neuronal survival (Jung, Jung, Kim, Han, & Kim, 2012).

The lack of intestinal microbiota has been shown to negatively affect health. Lactobacillus GG is safe at an early age and helps to reduce food allergies and associated inflammation. One of the reasons that breast-fed babies are thought to have fewer allergies is because breast milk contains beneficial microbiota. Even coming through the birth canal and being washed with the mother’s bacteria provides improved immune system health in contrast to Cesarean-section-born children.

If you are taking digestive enzymes and eating well, and yet still having digestive trouble, it is worth looking into simplifying how you are combining foods. Eating only one or two types of food that combine well together (foods that require similar acid- or alkaline-based enzymes) enhances digestion. For example: Are you combining large amounts of starch, like noodles, with protein foods like meat and then feeling digestive upset? Certain food combinations will not digest well because of the way digestion works. One way to think about food combining is to consider the mixing or combining of various paint colors; while you might mix any color together, if you mix several competing colors at once the results become muddied. While some colors work well together and enhance the overall palette, others do not. Food combining works in a similar way. Starches are digested in the mouth with the enzymes present in saliva, while protein is digested by stomach acid. If you ask the body to simultaneously produce both an acid environment (to digest protein) alongside alkalinizing enzymes in order to digest starches, it can delay digestion as the body figures out which food takes priority. This often leads to fermentation and gas.

Gas is a natural by-product of digestion of sugars and starches, and elimination via the oral route (belching) or anal route (flatulence) is normal. Excessive gas production can lead to discomfort or pain in the belly and even legs, and this signals poor digestion that will benefit from both digestive enzymes and the fine-tuning of food combinations. Beans are an example of a food containing a sugar called oligosaccharide, which is not digestible and thus leads to gas. Yet its benefit is experienced when it serves as a prebiotic once it reaches the colon .

When you eat starches and protein together, the starches can absorb the stomach acid and delay the digestion of protein. Food combining often requires that we go against established social dietary norms; we like baked potatoes (starch) and steak (protein) for dinner, or tuna or turkey sandwiches for lunch, or a fruit cup before a heavy dinner. Exploring individual reactions to food can begin simply by limiting food types at a meal and then experimenting with each combination to observe digestive reactions.

One can also add spices and herbs (called carminatives) to food that decrease the development of gas or aid its release once formed. Providing a handful of fennel seeds and licorice after an Indian meal is a practice of serving carminative herbs just like the Mexican culinary tradition of adding the green herb epazote (wormseed) to cooked beans. Adding black pepper, dill, basil, ginger, cardamom, and parsley to cooked or raw food also reduces gas, as does drinking a cup of peppermint tea following a meal.

Combine	With
Proteins	Nonstarchy/green vegetables
Fats and oils	Nonstarchy/green vegetables Vegetables Starches Proteins (use small amount of fat/oils)
Protein and fats	Nonstarchy/green vegetables Sour fruits
Grains and starches	Nonstarchy/green vegetables
Fermented dairy products	Nonstarchy/green vegetables Sour fruits Seeds and nuts
Beans and legumes	Nonstarchy/green vegetables Cultured vegetables
Fermented foods and drinks	Everything
Water and cold liquids	Nothing
Fruit	Nothing
Acid fruits	Subacid fruits
Subacid fruits	Acid or sweet fruits
Sweet fruits	Subacid fruits