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CME / ABIM MOC / CE

Can More Fruit, Veggie Intake Lessen Psychological Stress?

  • Authors: News Author: Nancy A. Melville; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 5/11/2017
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 5/11/2018
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Target Audience and Goal Statement

This article is intended for primary care clinicians, psychiatrists, nurses, neurologists, public health officials, and other members of the healthcare team involved in advising patients on diet and psychological stress.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Distinguish the association between fruit and vegetable intake and the prevalence and incidence of psychological distress among middle-aged and older adults, based on a cross-sectional, prospective Australian study
  • Determine the clinical implications of the association between fruit and vegetable intake and the prevalence and incidence of psychological distress among middle-aged and older adults


Disclosures

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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Nancy A Melville

    Freelance writer, Medscape

    Disclosures

    Disclosure: Nancy A. Melville has disclosed no relevant financial relationships.

Editor(s)

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.

CME Author(s)

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Alnylam; Biogen; Pfizer Inc.

CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Can More Fruit, Veggie Intake Lessen Psychological Stress?

Authors: News Author: Nancy A. Melville; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 5/11/2017

Valid for credit through: 5/11/2018

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Clinical Context

Given the global burden of mental disorders, there is an urgent mandate for public health strategies to prevent the onset of depression and other common psychiatric conditions. Increasing evidence supports an association of diet with overall and potentially mental health, particularly for fruit and vegetables, which appear to protect against cardiovascular disease, cancer, and other chronic diseases.

A recent meta-analysis suggested that a lower risk for depression is linked with fruit and vegetable consumption, and cross-sectional studies support that greater consumption of fruit and vegetables is associated with better mental health. The goal of this cross-sectional, prospective Australian study by Nguyen and colleagues was to investigate the association between fruit and vegetable intake and the prevalence and incidence of psychological distress among middle-aged and older adults.

Study Synopsis and Perspective

Consumption of fruits and vegetables, either separately or combined, is linked with a lower prevalence of psychological stress primarily in women, results of a large longitudinal study suggest.

"Our study, which is based on a large sample of more than 60,000 Australians, adds to the limited evidence base for a longitudinal association between mental well-being and fruit and vegetable intake. Our study is also novel in that it compares findings in men and women," first author Binh Nguyen, a PhD candidate and research officer in the Prevention Research Collaboration at the Sydney School of Public Health, University of Sydney, in Australia, told Medscape Medical News.

The study was published in the March issue of BMJ Open.[1]

Moderate Consumption

The study included 60,404 adults aged 45 years and older enrolled in the Sax Institute's 45 and Up Study. The participants completed surveys at baseline between 2006 and 2008 and were followed up in 2010.

The mean age of the participants was 62.2 years, and 53.6% were women. They reported consuming 2.0 mean daily servings of fruit and 3.9 mean daily servings of vegetables.

At a mean follow-up of 2.7 years, higher baseline levels of fruit and vegetable consumption, compared with 1 or no servings per day, were significantly associated with a lower prevalence of high to very high levels of psychological distress. This was defined as a score of 22 or higher on the 10-item validated Kessler Psychological Distress Scale (K10) (P =.01 to P <.001), after adjustment for sociodemographic and lifestyle risk factors.

Compared with those who consumed the lowest levels per day, those who consumed 3 to 4 daily servings of vegetables showed a 12% reduced risk for stress; those who ate 5 to 7 servings of fruit as well as vegetables had a 14% lower risk for stress compared with those who consumed 0 to 4 servings per day.

"Consumption of fruit and vegetables, considered separately or combined, was consistently associated with a lower prevalence of psychological distress. Following adjustment for all covariates, these associations were slightly attenuated compared with the unadjusted model but remained significant," the researchers write.

However, a longitudinal analysis showed that after full adjustment for confounders, the association was only significant with medium consumption, not high consumption.

In addition to age and sex, factors in the fully adjusted analyses included body mass index, smoking status, alcohol intake, physical activity, chronic disease, income, and education.

Further analysis stratifying the effects in women and men showed that the association with reduced stress was only significant in women (P ≤.001).

Women who consumed 3 to 4 daily servings of vegetables had an 18% reduced risk for stress compared with women who consumed 0 to 1 servings daily; those who consumed 2 servings of fruit had a 16% risk reduction, and those who ate 5 to 7 servings of fruits and vegetables combined had a 23% lower risk for stress.

"We did not expect to see these striking differences between men and women. We don't really know the reasons behind this, but perhaps women are better at reporting their fruit and vegetable intake," Nguyen said.

Surprise Finding

The finding that only medium, but not high, consumption of vegetables and fruits was associated with reduced stress was also a surprise, said Nguyen.

"Those who consume higher amounts of fruit and vegetables may also have been consuming big quantities of other types of foods which could lead to psychological distress," Nguyen said.

Mechanisms that could explain the link between fruit and vegetable consumption and overall psychological well-being include their rich compositions of micronutrients and phytochemicals, resulting in a reduction in oxidative stress and inflammation that are linked to mental health disorders, the authors speculate.

"Although more research is needed, potential mechanisms include that fruit and vegetables are high in antioxidants such as vitamins C and E. These can help reduce oxidative stress and inflammation, which can be harmful to mental health," said Nguyen.

Other large studies have shown inverse associations with psychological well-being. A recent meta-analysis of studies of fruit and vegetable consumption showed an inverse association with rates of depression.[2]

In addition, a recent Swiss survey of 20,220 adults showed that a daily recommended intake of 5 servings of fruit and vegetables was associated with a lower rate of high or moderate psychological distress.[3]

However, not all studies have shown psychological benefits after adjustment for the other healthy lifestyle factors that could be expected to accompany regular vegetable and fruit consumption.

For example, a longitudinal study of more than 8000 Canadians that was published last year in the BMJ showed improvement in depression and psychological distress linked with daily consumption of fruit and vegetables, but the association lost significance after the researchers adjusted for other health-related factors, including smoking and physical activity.[4]

"These findings suggest that relations between fruit and vegetable intake, other health-related behaviours and depression are complex," the authors of that study conclude.

"Behaviors such as smoking and physical activity may have a more important impact on depression than fruit and vegetable intake," they add.

The study received funding from a development award from the Cardiovascular Research Network of New South Wales. The authors have disclosed no relevant financial relationships.

BMJ Open. 2017;7:e014201.

Study Highlights

  • In New South Wales, 60,404 adults (53.6% women) aged 45 years and older (mean age, 62.2 years) completed questionnaires at baseline in 2006-2008 and at follow-up (mean, 2.7 years) in 2010.
  • Questions included the validated K10 for general anxiety and depression, and short validated questions for usual fruit and vegetable consumption (mean, 2.0 daily servings for fruit; 3.9 daily servings for vegetables).
  • High-to-very high levels of psychological distress (K10 score ≥22), occurred in 5.6% at baseline, and at follow-up in 4.0% without baseline distress.
  • Considered separately or together, higher baseline fruit and vegetable consumption was associated with a lower prevalence of baseline psychological distress, even after adjustment for sociodemographic and lifestyle risk factors with use of logistic regression models.
  • Risk for distress was 12% lower in those with 3 to 4 servings of vegetables daily vs those with the lowest intake, and 14% lower in those with 5 to 7 vs 0 to 4 servings of fruits and vegetables daily.
  • In models adjusted only for age and sex, baseline fruit and vegetable consumption, measured separately or combined, predicted a lower incidence of psychological distress during follow-up.
  • At medium intake levels, most of these associations remained significant, but at highest intake, these associations were no longer significant in fully adjusted models.
  • This trend suggests that those who consume healthy amounts of fruits and vegetables are more likely to have favorable socioeconomic status, physical activity, and other lifestyle risk factors promoting lower psychological distress, confounding the association.
  • The association of fruit and vegetable intake with prevalence and incidence of psychological distress was stronger in women (P ≤.001); there were no clear associations in men.
  • Risk for distress in women was 18% lower in those with 3 to 4 vs 0 to 1 servings of vegetables daily, and 23% lower in those with 5 to 7 servings of fruits and vegetables daily.
  • Longitudinal associations between fruit and vegetable intake and psychological distress declined the most between the age-adjusted, sex-adjusted, and fully adjusted models, suggesting confounding by age and sex.
  • On the basis of their findings, the investigators concluded that increasing fruit and vegetable intake may help lower psychological distress in middle-aged and older adults.
  • Because fruits and vegetables were more protective for women than for men, women may be more responsive to their dietary benefits, perhaps because of physiological differences, although women may more accurately report dietary intake.
  • Findings from this study support current public health guidelines recommending fruit and vegetable intake as part of a healthy diet.
  • However, the investigators recommend additional research on the association of fruit and vegetable intake with the incidence of psychological distress, particularly regarding a possible threshold effect between medium and higher intake levels, as well as sex differences in psychological benefit.
  • Mechanisms underlying the association between high fruit and vegetable consumption and better psychological well-being are unclear, but they may include micronutrients and phytochemicals lowering oxidative stress and inflammation.
  • Vitamins C and E, polyphenols, and other antioxidants may reduce oxidative stress, and magnesium is linked with lower levels of C-reactive protein.
  • Folic acid or other vitamin B deficiencies have been linked with depression and high homocysteine levels, which impairs methylation needed for synthesis and metabolism of neurotransmitters regulating mood.
  • Study limitations include possible reporting bias, reverse causation or residual confounding; fruit and vegetable consumption measured only once; and relatively short follow-up duration, which may have been insufficient to determine the full extent of long-term associations between fruit and vegetable consumption and psychological distress.

Clinical Implications

  • Higher baseline fruit and vegetable consumption was associated with a lower prevalence of psychological distress, even after adjustment for sociodemographic and lifestyle risk factors with use of logistic regression models, based on a cross-sectional, prospective Australian study.
  • The findings suggest that increasing fruit and vegetable intake may help lower psychological distress in middle-aged and older adults, but fruits and vegetables were more protective for women and at medium, but not higher, intake levels.
  • Implications for the Healthcare Team: Findings from this study support current public health guidelines recommending fruit and vegetable intake as part of a healthy diet and add evidence supporting the benefits of fruit and vegetables for mental health, but additional research is clearly needed.

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