A nutrition strategy to reduce the burden of diet related disease: access to dietician services must complement population health approaches

Poor diet quality is implicated in almost every disease and health issue. And yet, in most advanced market economies diet quality is poor, with a minority meeting guidelines for healthy eating. Poor diet is thus responsible for substantial disease burden. Societies have at their disposal a range of strategies to influence diet behaviors. These can be classified into: (i) population level socio-educational approaches to enhance diet knowledge; (ii) pricing incentives (subsidies on healthy foods, punitive taxes on unhealthy foods); (iii) regulations to modify the food environment, and (iv) the provision of clinical dietetic services. There is little evidence that societies are active in implementing the available strategies. Advertising of “junk foods” is largely unchecked, contrasting with strict controls on advertising tobacco products, which also attract punitive taxes. Access to dieticians is restricted in most countries, even in the context of universal health care. In Australia in 2011 there were just 2,969 practicing dieticians/nutritionists or 1.3 clinicians per 10,000 persons, compared with 5.8 physiotherapists per 10,000 persons, 14.8 general practitioners (family physicians) per 10,000 persons or 75 nurses per 10,000 persons. It is time to implement comprehensive national nutrition strategies capable of effecting change. Such strategies need to be multi-component, incorporating both public health approaches and expanded publicly funded dietetic services. Access to individualized dietetic services is needed by those at risk, or with current chronic conditions, given the complexity of the diet message, the need for professional support for behavior change and to reflect individual circumstances. The adoption of a comprehensive nutrition strategy offers the promise of substantial improvement in diet quality, better health and wellbeing and lower health care costs

A modified Mediterranean dietary intervention for adults with major depression: dietary protocol and feasibility data from the SMILES trial

Background: The SMILES trial was the first randomized controlled trial (RCT) explicitly designed to evaluate a dietary intervention, conducted by qualified dietitians, for reducing depressive symptomatology in adults with clinical depression.Objectives: Here we detail the development of the prescribed diet (modified Mediterranean diet (ModiMedDiet)) for individuals with major depressive disorders (MDDs) that was designed specifically for the SMILES trial. We also present data demonstrating the extent to which this intervention achieved improvements in diet quality.Methods: The ModiMedDiet was designed using a combination of existing dietary guidelines and scientific evidence from the emerging field of nutritional psychiatric epidemiology. Sixty-seven community dwelling individuals (Melbourne, Australia) aged 18 years or over, with current poor quality diets, and MDDs were enrolled into the SMILES trial. A retention rate of 93.9 and 73.5% was observed for the dietary intervention and social support control group, respectively. The dietary intervention (ModiMedDiet) consisted of seven individual nutrition counselling sessions delivered by a qualified dietitian. The control condition comprised a social support protocol matched to the same visit schedule and length.Results: This manuscript details the first prescriptive individualized dietary intervention delivered by dietitians for adults with major depression. Significant improvements in dietary quality were observed among individuals randomized to the ModiMedDiet group. These dietary improvements were also found to be associated with changes in depressive symptoms

Assessing healthy diet affordability in a cohort with major depressive disorders

Although, the cost of food is commonly described as a barrier to consuming a healthy diet, the evidence for this viewpoint has been inconsistent to date. The purpose of this study was to assess whether a healthy diet is affordable for a sample population with major depressive disorder and current unhealthy eating patterns, enrolled in supporting the modification of lifestyle in lowered emotional states (SMILES) trial. The first 20 participants of the SMILES trial were invited to complete a 7-day food diary at baseline. A cost analysis of a modified Mediterranean diet (recommended for trial participants) and 7-day food diaries of participants enrolled in the randomized controlled trial was conducted. Trial participants spent an estimated mean of $138 per week on food and beverages for personal consumption, whereas the total food and beverage costs per person per week for the recommended modified Mediterranean diet was estimated at$112, both based on mid-range product cost. The modified Mediterranean diet at $1.54 per mega-joules (MJ) was cheaper per energy unit than the cost of the current dietary intake of the SMILES participants included in this study at a mean of$2.35 per MJ. These study findings suggest that the adoption of a healthy modified Mediterranean diet does not cost more than a poor quality diet. Thus, failure to comply with healthy diets is unlikely to reflect affordability. Public health messages should incorporate the finding that healthy eating is not associated with increased costs and in fact may well involve savings to the household budget. Practical strategies and techniques for selecting healthy nutritious foods on a budget could support the achievement of desired dietary goals for preventing and managing chronic disease

Effects of a high-prebiotic diet versus probiotic supplements versus synbiotics on adult mental health : the "gut feelings" randomised controlled trial

Background: Preliminary evidence supports the use of dietary interventions and gut microbiota-targeted interventions such as probiotic or prebiotic supplementation for improving mental health. We report on the first randomised controlled trial (RCT) to examine the effects of a high-prebiotic dietary intervention and probiotic supplements on mental health. Methods: “Gut Feelings” was an 8-week, 2 × 2 factorial RCT of 119 adults with moderate psychological distress and low prebiotic food intake. Treatment arms: (1) probiotic supplement and diet-as-usual (probiotic group); (2) high-prebiotic diet and placebo supplement (prebiotic diet group); (3) probiotic supplement and high-prebiotic diet (synbiotic group); and (4) placebo supplement and diet-as-usual (placebo group). The primary outcome was assessment of total mood disturbance (TMD; Profile of Mood States Short Form) from baseline to 8 weeks. Secondary outcomes included anxiety, depression, stress, sleep, and wellbeing measures. Results: A modified intention-to-treat analysis using linear mixed effects models revealed that the prebiotic diet reduced TMD relative to placebo at 8 weeks [Cohen’s d = −0.60, 95% confidence interval (CI) = −1.18, −0.03; p = 0.039]. There was no evidence of symptom improvement from the probiotic (d = −0.19, 95% CI = −0.75, 0.38; p = 0.51) or synbiotic treatments (d = −0.03, 95% CI = −0.59, 0.53; p = 0.92). Improved anxiety, stress, and sleep were noted in response to the prebiotic diet while the probiotic tentatively improved wellbeing, relative to placebo. No benefit was found in response to the synbiotic intervention. All treatments were well tolerated with few adverse events. Conclusion: A high-prebiotic dietary intervention may improve mood, anxiety, stress, and sleep in adults with moderate psychological distress and low prebiotic intake. A synbiotic combination of high-prebiotic diet and probiotic supplement does not appear to have a beneficial effect on mental health outcomes, though further evidence is required. Results are limited by the relatively small sample size

Economic evaluation of a dietary intervention for adults with major depression (the "SMILES" trial)

BackgroundRecently, the efficacy of dietary improvement as a therapeutic intervention for moderate to severe depression was evaluated in a randomised controlled trial. The SMILES trial demonstrated a significant improvement in Montgomery&ndash;&Aring;sberg Depression Rating Scale scores favouring the dietary support group compared with a control group over 12 weeks. We used data collected within the trial to evaluate the cost-effectiveness of this novel intervention.MethodsIn this prospective economic evaluation, sixty-seven adults meeting DSM-IV criteria for a major depressive episode and reporting poor dietary quality were randomised to either seven sessions with a dietitian for dietary support or to an intensity matched social support (befriending) control condition. The primary outcome was Quality Adjusted Life Years (QALYs) as measured by the AQoL-8D, completed at baseline and 12 week follow-up (endpoint) assessment. Costs were evaluated from health sector and societal perspectives. The time required for intervention delivery was costed using hourly wage rates applied to the time in counselling sessions. Food and travel costs were also included in the societal perspective. Data on medications, medical services, workplace absenteeism and presenteesim (paid and unpaid) were collected from study participants using a resource-use questionnaire. Standard Australian unit costs for 2013/2014 were applied. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in average costs between groups divided by the difference in average QALYs. Confidence intervals were calculated using a non-parametric bootstrap procedure.ResultsCompared with the social support condition, average total health sector costs were $856 lower (95$2591 lower (95% CI -3591 to &minus;&thinsp;198) for those receiving dietary support. These differences were driven by lower costs arising from fewer allied and other health professional visits and lower costs of unpaid productivity. Significant differences in mean QALYs were not found between groups. However, 68 and 69% of bootstrap iterations showed the dietary support intervention was dominant (additional QALYs at less cost) from the health sector and societal perspectives.ConclusionsThis novel dietary support intervention was found to be likely cost-effective as an adjunctive treatment for depression from both health sector and societal perspectives.<br /

The SMILES trial: An important first step

The SMILES trial was the first intervention study to test dietary improvement as a treatment strategy for depression. Molendijk et al. propose that expectation bias and difficulties with blinding might account for the large effect size. While we acknowledge the issue of expectation bias in lifestyle intervention trials and indeed discuss this as a key limitation in our paper, we observed a strong correlation between dietary change and change in depression scores, which we argue is consistent with a causal effect and we believe unlikely to be an artefact of inadequate blinding. Since its publication, our results have been largely replicated and our recent economic evaluation of SMILES suggests that the benefits of our approach extend beyond depression. We argue that the SMILES trial should be considered an important, albeit preliminary, first step in the field of nutritional psychiatry research

A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial)

Correction to this article published: Jacka, FN, O'Neil, Adrienne, Opie, Rachelle, Itsiopoulos, Catherine, Cotton, SM, Mohebbi, M, Castle, David J, Dash, Sarah (external link), Mihalopoulos, Cathrine, Chatterton, Mary Lou, Brazionis, Laima, Dean, OM, Hodge, A. M and Berk, Michael (2018) Correction to: A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial). BMC Medicine, 16 (1). ISSN 1741-701

Correction to: A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial)

The original version of this paper [1] did not specify that a website was used in the final year of recruitment, in addition to the other stated recruitment methods. Corrigendum to: Jacka, FN, O'Neil, Adrienne, Opie, Rachelle, Itsiopoulos, Catherine, Cotton, Sue, Mohebbi, M, Castle, David, Dash, Sarah , Mihalopoulos, Cathrine, Chatterton, Mary Lou, Brazionis, Laima, Dean, OM, Hodge, Allison M and Berk, Michael (2017) A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial). BMC Medicine, 15. ISSN 1741-701

Evaluating telehealth lifestyle therapy versus telehealth psychotherapy for reducing depression in adults with COVID-19 related distress: the curbing anxiety and depression using lifestyle medicine (CALM) randomised non-inferiority trial protocol

BACKGROUND: There is increasing recognition of the substantial burden of mental health disorders at an individual and population level, including consequent demand on mental health services. Lifestyle-based mental healthcare offers an additional approach to existing services with potential to help alleviate system burden. Despite the latest Royal Australian New Zealand College of Psychiatrists guidelines recommending that lifestyle is a ‘first-line’, ‘non-negotiable’ treatment for mood disorders, few such programs exist within clinical practice. Additionally, there are limited data to determine whether lifestyle approaches are equivalent to established treatments. Using an individually randomised group treatment design, we aim to address this gap by evaluating an integrated lifestyle program (CALM) compared to an established therapy (psychotherapy), both delivered via telehealth. It is hypothesised that the CALM program will not be inferior to psychotherapy with respect to depressive symptoms at 8 weeks. METHODS: The study is being conducted in partnership with Barwon Health’s Mental Health, Drugs & Alcohol Service (Geelong, Victoria), from which 184 participants from its service and surrounding regions are being recruited. Eligible participants with elevated psychological distress are being randomised to CALM or psychotherapy. Each takes a trans-diagnostic approach, and comprises four weekly (weeks 1-4) and two fortnightly (weeks 6 and 8) 90-min, group-based sessions delivered via Zoom (digital video conferencing platform). CALM focuses on enhancing knowledge, behavioural skills and support for improving dietary and physical activity behaviours, delivered by an Accredited Exercise Physiologist and Accredited Practising Dietitian. Psychotherapy uses cognitive behavioural therapy (CBT) delivered by a Psychologist or Clinical Psychologist, and Provisional Psychologist. Data collection occurs at baseline and 8 weeks. The primary outcome is depressive symptoms (assessed via the Patient Health Questionnaire-9) at 8 weeks. Societal and healthcare costs will be estimated to determine the cost-effectiveness of the CALM program. A process evaluation will determine its reach, adoption, implementation and maintenance. DISCUSSION: If the CALM program is non-inferior to psychotherapy, this study will provide the first evidence to support lifestyle-based mental healthcare as an additional care model to support individuals experiencing psychological distress. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12621000387820, Registered 8 April 2021

A randomised, controlled trial of a dietary intervention for adults with major depression (the "SMILES" trial): study protocol

Despite increased investment in its recognition and treatment, depression remains a substantial health and economic burden worldwide. Current treatment strategies generally focus on biological and psychological pathways, largely neglecting the role of lifestyle. There is emerging evidence to suggest that diet and nutrition play an important role in the risk, and the genesis, of depression. However, there are limited data regarding the therapeutic impact of dietary changes on existing mental illness. Using a randomised controlled trial design, we aim to investigate the efficacy and cost-efficacy of a dietary program for the treatment of Major Depressive Episodes. <br /