Mental Health in Indonesia

Average prevalence 6.4% (Riskesdas, likely underestimated)

10.7% of the global burden of disease (WHO 2008)

~700 psychiatrists for 250 million people

80% seek help from traditional healers

Graphs: State of health inequality: Indonesia. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO
Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, World Health Organization
https://www.who.int/mental_health/evidence/atlas/profiles/idn_mh_profile.pdf?ua=1
Pols H. The development of psychiatry in Indonesia: from colonial to modern times. Int Rev Psychiatry. 2006 August;18(4):363–370
Graphs: State of health inequality: Indonesia. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO
Graphs: State of health inequality: Indonesia. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO
Mental Illness: Disease of Civilization?

“. . . it is remarkable that studies of truly indigenous

populations are virtually unanimous in reporting very
low rates of schizophrenia.”
—Prof Malcolm Peet
NHS Psychiatrist, University of Sheffield

Peet M. Nutrition and schizophrenia: an epidemiological and clinical perspective. Nutr Health. 2003;17:211-219.
Modern Diets and Mental Illness
Root Causes of Mental Illness

Inflammation
Oxidation
Mitochondrial Dysfunction
Low BDNF
Insulin Resistance
Root Cause: Nutrient Deficiencies Glucose/
Ketones
energy source

Cholesterol
Vitamins & Minerals synapses,
energy production, myelin,
neurotransmitter synthesis lipid rafts
Fat
insulation,
neurotransmission,
immune functions
Protein
neurotransmitters,
antioxidants

Micronutrients Macronutrients
 Cholesterol

Cholesterol can’t cross

the blood-brain barrier,
so the brain makes its own

Zhang J and Liu Q 2015. Cholesterol metabolism and homeostasis

in the brain. Protein Cell 6(4): 254-264.
The Brain Is ~60% Fat
25% MUFA
(mainly oleic)
50% PUFA 25% Saturated
(mainly DHA
and ARA)
DHA plays a “unique and indispensable role” in the
“neural signaling essential for higher intelligence.”
—Simon Dyall PhD, Lipid Research Scientist
Bournemouth University, UK
Dyall SC. Long-chain omega-3 fatty acids and the brain: a review of the independent and shared effects of EPA, DPA and DHA. Front Aging Neurosci. 2015;7(52).
Image credit: nexusplexus / 123RF Stock Photo
3 Types of Omega-3
Anti- Synapses, Myelin,
inflammatory Mitochondria

ALA EPA DHA

0-9%

plant & oily fish

animal fats pastured organ meats
pastured animal fats
 Nutrient Animals Plants
Folate (B9) ✓ ✓
Vitamin C ✓ ✓
Vitamin E ✓ ✓
Vitamin K1 ✓ ✓

Iron ✓ non-heme
≥3x more bioavailable

Vitamin A ✓ carotenoids
12-24x more bioavailable

Vitamin D ✓ D2
D3—easier to use/store
Full complement of only quinoa, soy,
✓
amino acids buckwheat
B12 ✓ ✗
Vitamin K2 (MK-4) ✓ ✗
EPA, DHA, ARA ✓ ✗
 Plant Anti-Mineral Activity

Goitrogens Iodine
soy
cassava

Phytate Iron, Zinc, Calcium,

grains and Magnesium
beans
nuts
seeds
Mind Minerals
Dopamine synthesis, infant brain development, neurotransmitter
synthesis, hippocampal function, energy production, cell signaling1

Converts B6 to active form, serotonin synthesis, dopamine

transport1

Brain growth and development, proper functioning of the thyroid

(Iodine deficiency #1 cause of childhood brain damage)2
1Villagomez A, Ramtekkar U. Iron, magnesium, vitamin d, and zinc deficiencies in children presenting with symptoms of Attention-Deficit/Hyperactivity Disorder.
Children. 2014;1:261-279.
2WHO. Is it true that lack of iodine really causes brain damage? WHO website. Updated May 2013.
 Common Deficiencies in Indonesia

Nutrient Key Brain Function

Zinc neurotransmitter synthesis
Iron neurotransmitter synthesis
Vitamin B6 neurotransmitter synthesis
Vitamin B12 myelin synthesis
Vitamin A vision, learning, memory
Vitamin D3 calcium regulation
Iodine thyroid function, brain development
 The “SAD” Western Diet
now exported around the world…

Sugar consumption Vegetable oil

Indonesia SE Asia

18% 100%
2010-20131 1980-20002

1. Atmartia MPH et al. Consumption and sources of added sugar in Indonesia: a review. Asia Pac J Clin Nutr. 2018;27(1):47-64.
2. Spohrer R et al. The growing importance of staple foods and condiments used as ingredients in the food industry and implications for large-scale food fortification programs
in Southeast Asia. Food and Nutrition Bulletin. 2013;34(2):supplement.
 Root Cause:
Inflammation / Oxidation
Depression & Bipolar Disorder
linked to inflammation

Depression, Bipolar Disorder,

Schizophrenia, OCD
linked to oxidation
Serafini G et al. The role of inflammatory cytokines in suicidal behavior: a systematic review. Eur Neuropsychopharmacol. 2013;23(12):1672-1686.
Goldstein BI et al. Inflammation and the phenomenology, pathophysiology, comorbidity, and treatment of bipolar disorder: a systematic review. J Clin Psychiatry. 2009;70:1078-1090.
Najjar S et al. Neuroinflammation and psychiatric illness. J Neuroinflammation. 2013;10:43.
Omega 3 Omega 6
Anti-Inflammation Pro-Inflammation

EPA LA

Excessive intake
of refined seed oil
 High blood sugar
and insulin levels
promote
Inflammation &
Oxidation

Brownlee M. Biochemistry and molecular cell biology of diabetic complications. Nature. 2001;414(6865): 813-820.
Ghasemi R et al. Brain insulin dysregulation: implication for neurological and neuropsychiatric disorders. Mol Neurobiol. 2013,47(3):1045-1065.
Kiecolt-Glaser JK. Stress, food, and inflammation: psychoneuroimmunology and nutrition at the cutting edge. Psychosomatic Medicine. 2010, 72(4):365-369.
What Is Oxidation?
Root Cause: Hormonal Roller Coaster

Data sources: Benton D. Carbohydrate ingestion, blood glucose and mood. Neurosci Biobehav Rev. 2002;26:293-308.
Daly ME et al. Acute effects on insulin sensitivity and diurnal metabolic profiles of a high-sucrose compared with a high-starch diet. Am J Clin Nutr. 1998; 67:1186-
96.
Sugar + Teenaged Boys = STRESS

4-5x increase!

Adapted from Jones TW. Enhanced adrenomedullary response and increased susceptibility to neuroglycopenia: mechanisms underlying the adverse effects of sugar
ingestion in healthy children. J Pediatr. 1995;126(2):171-7.
Root Cause: Neurotransmitter
Imbalances
Serotonin
(mood)
Dopamine
(attention, pleasure, motivation)
Melatonin
(sleep)
Glutamate / GABA
(overall activity level of the brain)
The Kynurenine Pathway
Dopamine
Oxidation
Inflammation GABA KYNA
Stress

Protein Tryptophan KYN

Serotonin &
Glutamate QUIN
Melatonin
Brietzke E et al. Ketogenic diet as a metabolic therapy for mood disorders: evidence and developments. Neurosci Biobehav Rev. 2018; Nov;94:11-16.
Fujigaki H et al. L-Tryptophan-kynurenine pathway enzymes are therapeutic target for neuropsychiatric diseases. Neuropharmacology. 2017 Jan;112(Pt B):264-274
Stone TW, Darlington G. The kynurenine pathway as a therapeutic target in cognitive and neurodegenerative disorders. Br J Pharmacol. 2013 Jul;169(6):1211-1227.
 Inflammation & Oxidation Cause
Brain Damage
• Decreases BDNF (neuroplasticity)

• Damages proteins, lipids, DNA, mitochondria and the blood-brain

barrier

• Shrinks the hippocampus

Root Cause: Insulin Resistance

Glucose

Insulin

de la Monte SM, Wands JR. Alzheimer's disease is type 3 diabetes—evidence reviewed. J Diabetes Sci Technol. 2008;2(6):1101-1113.
Insulin Resistance and Depression?

PPAR-γ Agonists
Improved depression symptoms in 7 out of 8 studies1

Pure anti-inflammatory medications like Celecoxib (Celebrex) can

also help in some cases

1.Colle R et al. PPAR-γ agonists for the treatment of major depression: a review. Pharmacopsychiatry. 2017 Mar;50(2):49-55.
Watson K et al. Insulin resistance, an unmasked culprit in depressive disorders: promises for interventions. Neuropharmacology. 2018 Jul 1;136(Pt B):327-334.
Liu CS. Evidence for inflammation-associated depression. Curr Top Behav Neurosci. 2017;31:3-30.
Insulin Resistance and Psychosis

People diagnosed with schizophrenia more likely to have

glucose regulation problems and insulin resistance

. . . even if they’ve never taken antipsychotic medications

Pillinger T. Glucose homeostasis in first-episode schizophrenia: a systematic review and meta-analysis. JAMA Psychiatry. 2017 Mar 1;74(3):261-269.
Insulin Resistance and Bipolar Disorder

Bipolar types 1 and 2

32%
121 patients, age 30’s–50’s
More likely:
IR
Chronic symptoms
Rapid-cycling
Lithium-refractory (BMI predictive) 22%

DMII
Calkin CV et al. Insulin resistance in bipolar disorder: relevance to routine clinical care. Bipolar Disord. 2015;17:683-688.
Bipolar Disorder = Emotional Epilepsy?
Na+
Na+
Na+ Na+
Na+ Na+ Na+ Na+
Na+

Anti-Convulsant
Ketogenic Diet
Mood Stabilizers

Na+
Na+ Na+

Mula M, Marotta AE, Monaco F. Epilepsy and bipolar disorders. Expert Rev Neurother. 2010 Jan;10(1):13-23.
Knott S et al. Epilepsy and bipolar disorder. Epilepsy Behav. 2015 Nov;52(Pt A):267-74.
Wiglusz MS et al. Overlapping phenomena of bipolar disorder and epilepsy—a common pharmacological pathway. Psychiatr Danub. 2015 Sep;27 Suppl 1:S177-81.
What Does the Science Say?
Epilepsy Autism
Parkinson’s Disease Alzheimer’s Disease
ALS
Traumatic Brain Injury Bipolar Disorder
Multiple Sclerosis Schizophrenia

https://www.psychologytoday.com/blog/diagnosis-diet/201706/ketogenic-diets-psychiatric-disorders-new-2017-review
RCTs of Diet and
Psychiatric Disorders
1. SMILES (Mediterranean + nuts/olive oil)
2. HELFIMED (Mediterranean + fish oil)

Mediterranean Diet (modestly)

improves symptoms of depression
(when added to pre-existing treatments)

Jacka F et al. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’
trial). BMC Med. 2017;5:23.
Parletta N et al. A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and
mental health in people with depression: a randomized controlled trial (HELFIMED). Nutr Neuro. 2017 Dec;7:1-14.
Image credit: julijadm / 123RF Stock Photo
 21 Century Indonesia Faces
st

Double Burden of Malnutrition

Malnutrition PLUS Obesity

Child underweight 21% , Child stunting 37% (both improving!)

Child obesity 10% 16.5% (worsening!)
[1993-2007 (14 yrs)]

Not enough of the right foods (nutrients)

Too much of the wrong foods (metabolic damage)
Rachmi CN et al. Stunting, underweight and overweight in children aged 2.0–4.9 years in Indonesia: prevalence trends and associated risk factors. PLOS ONE. 2016;11(5):e0154756.
Indonesian
Food Supply
1990-2011
Total dietary energy supply = 2,713 (2011)
(kcal/person/year)

UN FAO Food Balance Sheets. 2014 Update—Indonesia - Food and Nutrition Security Profiles.
Dietary Guidelines Do Not Adequately
Address Root Causes
• Based on low-nutrient starchy staples that contribute to nutrient
deficiencies AND are unsafe for those with insulin resistance
• Discourage nutrient-rich animal protein and animal fat
• They do limit sugar (good!)
• BUT they explicitly recommend processed starches and processed
vegetable oils.
Ketogenic Diets Address Root
Causes
• High in nutrients
• Low in antinutrients
• Reduces inflammation/oxidation
• Reduces insulin resistance
• Increases BDNF
• Rebalances neurotransmitters
• Improves mitochondrial function

Brietzke E et al. Neuroscience and Biobehavioral Reviews 2018: Ketogenic diet as a metabolic therapy for mood disorders: evidence and developments. Neurosci
Biobehav Rev. 2018 Nov;94:11-16
Careful with Medications…

https://www.psychologytoday.com/us/blog/diagnosis-diet/201803/ketogenic-diets-and-psychiatric-medications
 Subtraction Is Difficult, But
Powerful

“At the neurobiological level, the neural substrates

of sugar and sweet reward appear to be
more robust than those of cocaine.”1

1Ahmed SH et al. Sugar addiction: pushing the drug-sugar analogy to the limit.. Curr Opin Clin Nutr Metab Care. 2013;16(4):434-439.
Bellisle F et al. Sweetness, satiation, and satiety. J Nutr. 2012;142:1149s-54s. doi: 10.3945/jn.111.149583.
What Is a Brain-Healthy Diet?
AVOID
Sugar, fruit juice, sweets
Flour, noodles, baked goods
Refined seed oils (soybean,
sunflower, canola, etc.).
Unrefined palm fruit and palm
kernel oil ok.
Grains (white rice ok if no IR)
ENJOY
Meat, seafood, poultry, eggs
Non-starchy vegetables
Animal fat, palm fruit oil
Virgin coconut oil, nuts
Fruit, starchy veg, sago ok if no
IR
Connect with Me!
www.diagnosisdiet.com
psychologytoday.com/blog/diagnosis-diet

@GeorgiaEdeMD

/GeorgiaEdeMD

Special thanks to Suzi Smith for presentation design and graphics