Depression and anxiety are extremely common conditions that affect millions of children in the United States. The CDC estimates 9.4% of children have clinically significant anxiety, and 4.4% of children have depression. This represents over 5 million anxious children and 2.5 million depressed children in the United States alone. UNICEF estimates globally 13% of adolescents have a mental health disorder. Even more concerning is the fact that this data is from a pre-pandemic era (2016-2019), and rates are almost certainly significantly higher. Most children in the United States with mental health disorders are treated by their pediatricians with a combination of counseling or therapy and medications. But from a naturopathic perspective, the use of nutrition as a primary intervention for pediatric mental health disorders is extremely underutilized in pediatric primary care.
My experience with pediatric anxiety and depression as a primary care provider
Anxiety is the most common mental health complaint of pediatric patients in my practice, closely followed by ADHD. Behavior problems are another extremely common complaint by parents of the patients in my practice. Concerningly, many parents do not recognize that their child’s “behavior” problems can actually be a sign of pediatric depression. Very few children self-report depression or even sadness, where many children have signs of irritability, “crankiness,” defiance, withdrawal and more.
Common signs of pediatric anxiety and depression
Common signs of pediatric anxiety include: frequent and/or excessive worries, severe fears or phobias (i.e., separation, darkness, animals, fires, deaths, etc), frequent fidgeting, tension, poor appetite, constipation or diarrhea, recurrent stomachaches of no known cause, headaches, difficulty concentrating, insomnia, refusal to go to school or other social activities. Some children with anxiety also experience bedwetting or daytime urinary or stool accidents. Selective mutism and OCD are variants of anxiety. In my opinion, Pathological Demand Avoidance is closely related to anxiety, though it is considered a subset of autism.
Common signs of pediatric depression include: irritability, “moodiness,” low self-esteem, inattention, changes in sleep patterns, not wanting to engage in fun activities, expressing a sense of guilt, saying “I’m useless” (or similar terms), eating more or less than usual, destructive behavior and fatigue. Please note that it is not normal for children to be fatigued (except when obviously sleep deprived). All children with significant fatigue should have a full medical workup, in my very humble medical opinion.
Addressing the underlying cause of pediatric anxiety and depression
Naturopathic doctors always look to address the underlying cause of the mood disorder. In most cases this includes screening bloodwork to rule out anemia and other metabolic conditions. In my office I typically run a complete blood count (CBC) with differential, TSH, comprehensive metabolic panel, vitamin D (as my practice is in Montana), ferritin, and whole blood lead. Many of these labs are to screen for common pediatric conditions, and are not necessarily specific to screening for mood disorders. However, it is truly remarkable how many children have their anxiety and depression improve when blood levels of vitamin D and iron (ferritin) normalize. Other optional labs may include a celiac screening test for any child with stomachaches/constipation/diarrhea, homocysteine or serum B12/folate for cases of suspected significant nutrient deficiencies. All adolescents should have screening fasting lipid tests completed. Some studies show that low cholesterol (<150 mg/dL) is associated with anxiety and depression. A full workup for pediatric patients with anxiety and depression goes beyond what can be listed in this article.
Naturopathic doctors understand how critical nutrition is for supporting mental health. Studies show that diets low in critical nutrients are linked to mood disorders in children. Though studies are lacking in children, research shows that adults who consume a diet low in magnesium, folate and zinc are more likely to be depressed. Similarly, adults who have diets low in essential fatty acids tend to have higher rates of anxiety and depression. Children are especially at risk for nutrient deficiencies due to their rapid growth and development and high need for these critical vitamins and minerals.
As a provider I often screen for nutrient deficiencies by simply completing a brief diet-diary in-office. (E.g., “what do you normally have for breakfast? Lunch? …”) I also ask parents about their child’s preferences, e.g., “is she a picky eater, or does she eat everything given to her?” Some children have what I call “Beige Syndrome,” where the majority of their diet is nutrient-poor beige-colored starches. I find it very important to never criticize families for their nutritional choices. In general I try to teach parents what to add to their child’s diet rather than focus on what to take away. I use the Harvard Healthy Eating Plate frequently when teaching children how to add vegetables, proteins, fruits and whole grains to their diet.
Nutritional interventions for pediatric anxiety and depression
Symptoms of hypoglycemia (low blood sugar) include anxiety, sweating, irritability, hunger, shaking, anger, confusion, poor concentration and fatigue. Note how many of these symptoms overlap with the general signs of anxiety. Hypoglycemia often can mimic anxiety or depression, and can be surprisingly difficult to determine in children who often lack the awareness of their hunger cues. Reactive hypoglycemia is common in patients eating a high-carbohydrate, “Standard American Diet” (SAD). Reactive hypoglycemia occurs when insulin is secreted after a high carbohydrate meal, leading to low blood glucose levels in the hours following. Reactive hypoglycemia can occur any time within 4 hours of a high-carbohydrate meal, but typically I see parents or patients report a “blood sugar crash” right about 90 minutes after eating.
Parents can reduce symptoms of hypoglycemia by working on balancing blood sugar. This includes feeding children meals high in protein, fiber and healthy fats. This should be especially emphasized at breakfast. Excellent breakfast options are sandwiches or wraps, breakfast scrambles with veggies (with or without eggs), yogurt with nuts and berries, protein-containing smoothies, whole grain products with nut butter, oatmeal or quinoa with berries or fruit. Refined products like white bread, bagels, donuts or pastries should be avoided, at least on a regular basis. As I tell my patients, “these foods taste great and are fun to eat, but they are better to have as Sometimes foods rather than Everyday foods.”
Gluten-free baked goods are notoriously low in fiber, and families who are eating low or no-gluten diets should be careful to add additional fiber and protein. Nut flours like almond, coconut or pecan-flour breads and muffins are higher protein and fiber alternatives to many gluten-free products. Specific Carbohydrate Diet baked goods are especially great options for nut-tolerant children. Many patients on a Specific Carbohydrate diet notice significant improvements in mood. This may be due to blood-sugar balancing, promoting a healthy microbiome (see below), or simply because the foods are highly nutritious and nutrient-dense.
Eliminate artificial sweeteners, colors and flavorings
Some, but not all patients react negatively to artificial ingredients including sweeteners, preservatives, colorings, flavorings and other additives. In my office I recommend a 30-day trial elimination diet to assess whether the child is sensitive to any of these ingredients. I tell parents to eliminate all food colorings and additives, and to be sure to read food labels carefully. Most common reactions are to Allura Red (Red #40), Sunset Yellow (Yellow #6), Carmoisine (Red #3), Tartrazine (Yellow #5), Ponceau (Red #5 and others), Quinoline yellow (Yellow #13), aspartame, preservatives like sodium benzoate, BHA, BHT, TBHQ and others. Natural colorings are typically considered “okay” and include turmeric, beta-carotene, grape skin extract and others. Parents can check out the Feingold Association for more information on a food additive-free diet.
The patient (and parent/s) should notice significant improvement over the course of the 30 days. After the 30-day trial is complete the parents should add the foods back in to the patient’s diet (the “challenge” portion of the diet). If they notice a significant worsening of symptoms following the “challenge” then it confirms additive sensitivity. Children only need to continue to eliminate ingredients they are sensitive to. Though, for obvious reasons we prefer them to continue to consume a diet low in additives for general health purposes.
Add foods that improve the microbiome
A wealth of information now exists on the relationship between intestinal health, the microbiome and mental health. Research clearly shows altered microbiome in patients with anxiety. Whether this is a cause or effect of anxiety is yet to be determined, but some research does show that yogurt or probiotic supplementation can improve mood disorders. The research was completed in adults, but there is no reason to believe that children would have different outcomes. Lactobacillus rhamnosus, Lactobacillus helveticus, and Bifidobacterium longum have the best evidence currently, with some new promising research with Lactobacillus reuterii.
Add foods high in tryptophan
Tryptophan is the amino acid precursor to serotonin. Adequate serotonin in the brain contributes to feelings of relaxation, calmness, improved focus and overall wellbeing. Low serotonin has been linked to anxiety and depression. While many common medications aim to improve serotonin levels by acting as reuptake inhibitors (e.g., Prozac, Zoloft, etc), most naturopathic physicians aim to improve serotonin levels naturally. Children with poor protein consumption tend to have worse symptoms of anxiety and depression. Increasing dietary tryptophan can be very helpful in these cases. Foods with tryptophan include lean poultry (chicken, turkey or duck), beef, pork, tofu, and salmon. Lower but still significant amounts of tryptophan are found in milk products, beans, most nuts and seeds, and many whole grains including oats, quinoa and teff. Anxious patients should have sources of tryptophan at each meal.
Add foods high in vitamin B6 improve serotonin production
Pyridoxine, or vitamin B6 is the main cofactor involved in serotonin production. One small study of hyperactive children showed that pyridoxine supplementation improved serotonin levels. Vitamin B6 is also a critical nutrient in over one hundred different enzymatic reactions in the body, including protein metabolism, hormone function, fatty acid metabolism and more. B6 is also required in the step-by-step process for making other neurotransmitters as well, including dopamine, glycine, and GABA.
Because long-term, high-dose vitamin B6 supplementation can cause neuropathy (nerve damage), adding food sources of vitamin B6 is a significantly safer approach for patients with anxiety and depression. Excellent vitamin B6-containing foods include beef liver, salmon, banana, chickpeas, avocado, turkey, and more. Here is a full list.
Add foods high in vitamin B12 and folate
B12 and folate are necessary for the essential one-carbon metabolic process called methylation. Methylation is necessary for many functions in the human body, from CoQ10 synthesis, RNA and DNA formation, energy production, neurotransmitter synthesis, histamine degradation, phase II liver detoxification, and many more processes. Because methylation is so critical for normal brain function,
Add foods high in choline
Choline is an organic compound that is structurally similar to B vitamins. Choline is involved in fat transport and metabolism, cell structure (it forms the backbone of phosphatidylcholine which is the main component of the cell membrane), cell signaling, and the regulation of cell volume. Most importantly, choline is required to make acetylcholine which is a neurotransmitter with multiple critical functions. Acetylcholine plays a role in attention, alertness, and memory. Depletion of acetylcholine is associated with Alzheimer’s disease, fatty liver disease (NAFLD), and muscle damage. One study also showed an association between anxiety (but not depression) and low plasma choline levels. Studies show that maternal choline intake affects infant cognition and attention.
Food sources of choline include egg yolk, organ meats, fish (especially salmon), soybeans, beef, wheat germ, chicken and turkey, and cruciferous vegetables like broccoli and kale. See a full list here.
Add foods high in zinc
Zinc, like vitamins B6, folate and B12, is involved in an astonishing number of enzymatic processes. Because zinc stabilizes the folding of many proteins, it is absolutely critical for human survival. Zinc also plays an important role in gene expression. Zinc increases bioavailability of folate, which makes this important mineral even more important in mental health functions. Studies shows that low zinc levels are associated with lower levels of the calming neurotransmitter GABA, making zinc deficiency directly linked to anxiety.
Zinc containing foods include oysters, beef, crab, pork, chicken, pumpkin seeds, cashews and more. See a full list here.
Add Omega-3-containing foods, particularly eicosapentaenoic acid (EPA)
A number of studies have shown the benefit of diets high in Omega-3 fatty acids, particularly fats from cold water fish. In addition to mental health benefits, Omega-3 fat consumption has been shown to reduce cardiovascular disease risk, reduce eczema severity, improve autoimmune disease symptoms like lupus (in some situations), and may help protect against certain cancers. Deficiencies of omega-3 fatty acids have been linked to depression, bipolar disorder and dementia. One large meta-analysis shows that Omega-3 fatty-acid products high in EPA, but not DHA, are effective in the treatment of depression.
Cold water fatty fish is the best source of Omega-3 fatty acids, and particularly EPA. This could include salmon, sardines, herring, and mackerel. Some tuna is high in EPA, but it should be used cautiously due to high levels of mercury.
Putting it all together – a Mediterranean-type diet, Specific Carbohydrate Diet, or Nordic diet
Naturopathic physicians like myself strongly advocate well-rounded, nutrient-dense nutritional plans for their anxious and depressed patients. I use the term “diet” with caution, as many patients equate “diet” to “dieting” or calorie restriction, which typically is not the case when working with pediatric patients. Many of the best nutritional plans unfortunately use the term “diet” as descriptors (as, I suppose saying the “Mediterranean Nutritional Program” may get a bit wordy).
My favorites are the Mediterranean diet, Specific Carbohydrate Diet, and the newly researched Nordic Diet.
The main features of a Mediterranean diet are whole grains, beans, colorful vegetables, nuts, seeds, anti-inflammatory proteins like cold water fish, and copious olive oil. The Mediterranean diet has been specifically studied for its benefits on mental health. Additionally, the Mediterranean diet reduces risk of heart disease, diabetes, infertility, asthma, certain cancers, and frailty in the elderly.
If your patient does not tolerate beans I would recommend the Specific Carbohydrate Diet (SCD for short). SCD is best known for its impact on the microbiome, and is used primarily for patients with Crohn’s disease and Ulcerative Colitis. Seattle Children’s IBD center is leading the research into this fantastic nutritional approach for intestinal health. I use SCD regularly in my practice for patients with autism, or for patients with combined gastrointestinal and mental health disorders (i.e., a patient with IBS and anxiety). SCD is high in critical nutrients like zinc, B12, folate, iron, tryptophan and choline. However, special attention should be given to ensure the patient is receiving adequate fatty acids. SCD is great for patients who do not tolerate grains or who have gluten sensitivity or celiac disease.
Newly published research shows that a Nordic Diet improves anxiety, depression and stress in young women. A Nordic Diet is somewhat similar to the Mediterranean Diet, but includes more regional-specific foods like cruciferous vegetables, wild berries, cold water fish, whole grains like rye, barley or oats, fermented milk products, and rapeseed oil or canola oil. It is interesting that even though the omega fatty acid profile of canola oil is nowhere near as favorable as olive oil, the diet still has favorable effects.
Finally, it is incredibly important for parents to make sure their anxious or depressed children are getting regular meals with protein, fiber and healthy fats to help stabilize blood sugar. Parents should not be expected to be perfect, and the diets may take some time to implement. Parents will see best improvement in their child’s focus, attention, and mood at about 3-4 weeks when staying 80-90% compliant on the diet.
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