1 | OPTIMUM NUTRITION ENEWS |APRIL 2011

NEWS ANTIOXIDANTS TO IMPROVE MALE FERTILITY/EXPOSURE TO SOLID FOODS AND COW’S MILK ION CONFERENCE NEW BEGINNINGS COVER STORY POSTNATAL DEPRESSION ION SEMINAR CANCER SIGNS SCIENTIFIC MONThlY SEXUAL ACTIVITY AND DYSFUNCTION RECIPES RECIPES FROM THE FORESIGHT WHOLEFOOD COOKBOOK CASE STUDY HEAVY METALS AND FERTILITY ION CLINIC FERTILITY MOT

Optimum Nutrition

ENewsM A Y 2 0 1 1 | I S S U E 4

PostnatalDepressionExploring a Troubling Condition and Research into Contributory Factors

2 | OPTIMUM NUTRITION ENEWS | MAY 2011

Optimum Nutrition

ENewsM A Y 2 0 1 1 | I S S U E 4

EditorGail Wilson dipION

ContributorsAlexandra Rock DipION & Cornelia Dyball DipION(Cover Story)

Nicola Pearson(Scientifi c Monthly)

Nicola Moore dipION (Case Study)

Foresight (Recipes)

Design Jonathan Phillipsjon@toccatadesign.com

SubscriptionsGail Wilson020 8614 9052gail.wilson@ion.ac.uk

General Enquiriesonenews@ion.ac.uk

Optimum Nutrition ENews is provided by the Institute for Optimum Nutrition. The editorial expressed in this title are not necessarily those of the publisher. ION does not recommend or guarantee third-party products advertised or mentioned in this newsletter. Errors or omissions are in no way the responsibility of ION. Information is correct at the time of distribution. ION advises that you consult a health professional (e.g. nutritional therapist, GP) before embarking on a nutritional regime.

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A WORD from the ENEWS team

Dear Reader,Welcome to the May issue of Optimum Nutrition ENews.

OurNew Beginnings: The Nutritional Needs of Procreation Conference 2011 on18thJune2011isfastapproaching.Sothismonthwefocusonfertility,sexualfunction,pre-conceptualcareandpostnataldepression.Ifyouhaven’talreadybookedyourplacepleaseseepage4formoredetails.

Forthisissue,inthecoverstory,AlexandraRockDipIONandCorneliaDyball DipION discussthecontributoryfactorsinvolvedinpostnataldepression,whichmayaffectasmanyas10–15%ofwomen.AlexandrawillalsobespeakingattheConference.

InourScientificMonthly,NicolaPearsonreviewsthelatestresearchonSexualActivityandDysfunctionandhowdietcanhelp.

ThisissueweprovidesomehealthyrecipesfromtheForesightWholefoodCookbook.BelindaBarnes,FellowofIONandFounderofForesight,theAssociationforthePromotionofPre-conceptualCare,willalsobespeakingattheConference.

AndNicolaMooreDipIONsharesafertilitycasestudyfromtheIONClinicinwhichheavymetalswerefoundtobecontributingtoinfertility.NicolawillalsobesharingmorecasestudiesfromtheIONClinicattheConference.TheIONClinicisnowofferingaFertilityMOT–pleaseseepage21formoredetails.

Finally,wewouldliketoremindyouofournextworkshopsandCPDevents:

28th May – Cancer Signs and Natural Approaches with XandriaWilliams

23rd June – ‘How to’ of Healthy Weaning with AlisonPeacham DipION and BelindaBlake DipION

Pleasevisit www.ion.ac.uk/cpdseminars.htmformoredetails

Wehopeyouenjoythisissueandwishyouthebestofhealth,

the ENEWS TeamIf you like what you read and you are interested in writing for us, then we would like to hear from you. You can drop us an email at onenews@ion.ac.uk and we will get back to you with further information.

03 NEWS

04 ION Conference – 18th June 2011

05 COVER STORY: Postnatal Depression - Exploring a Troubling Condition and Research into Contributory Factors By Alexandra Rock & Cornelia Dyball

08 ION seminar - Cancer Signs and Natural Approaches

09 How to of Healthy Weaning – 23rd June

10 SCIENTIFIC MONTHLYSexual Activity and Dysfunction By Nicola Pearson

14 Bonusan 2 Day Course – Introduction to Clinical Psychoneuroimmunology – 8th & 9th June 2011

15 RECIPE SPOTLIGHT Recipes from The Foresight

Wholefood Cookbook

18 ION Home Study Course

19 SUCCESS STORIES: Heavy Metals and Fertility by Nicola Moore DipION

21 Fertility MOT at the ION Clinic

22 The ION Clinic

In this issue...

5 | OPTIMUM NUTRITION ENEWS | MAY 2011

Postnatal Depression – Exploring a Troubling Condition and Research into Contributory Factors

Postnatal depression (PND) is a debilitating mood disorder thought to affect between 10 to 15% of women1, with estimates of recurrence in subsequent pregnancies varying between 35 and 75%2,3. PND represents a considerable health risk to both women and their families1. It may begin during pregnancy or up to several months after delivery, and although the Diagnostic and Statistical Manual of Mental Disorders DSM-IV specifi es that the symptoms must begin four weeks after delivery4, many clinicians believe women are at risk for up to a year after giving birth5,6. PND appears to be an under-diagnosed condition, with estimates of up to 50% of cases remaining unreported as they either go unrecognised or mothers fail to seek treatment through being in denial7,8. If untreated, symptoms commonly resolve in six months but can persist for up to three years9 and have serious health consequences for mother and child10.

Early detection remains a challenge and relies on identifying those at risk, preferably during early pregnancy. Risk factors include genetic predisposition and environmental factors including social, psychological and biological, including nutrition defi ciencies6. A number of tools have been developed to enhance diagnosis. The Edinburgh Postnatal Depression Scale (EPDS) comprises a ten-item questionnaire9 and represents an easy to use screening tool11. More recently, a three-item subscale of the EPDS showed equivalent reliability at detecting PND which makes it an attractive screening tool for clinical use12. Beck (2002) devised a Postpartum Depression Predictors Inventory revised to include questions around 13 signifi cant risk factors (see table opposite). PND symptoms are similar to those of depression at other times of life such as mood swings, sleep disturbance, change in appetite, poor concentration and irritability, and additionally mothers experience guilt about their inability to care for their baby13.

By Alexandra Rock and Cornelia Dyball

COVER STORY

Postnatal depression (PND) is a debilitating mood disorder thought to affect between 10 to 15% of womenin subsequent pregnancies varying between 35 and 75%a considerable health risk to both women and their familiespregnancy or up to several months after delivery, and although the Diagnostic and Statistical Manual of Mental Disorders DSM-IV specifi es that the symptoms must begin four weeks after deliverymany clinicians believe women are at risk for up to a year after giving birthPND appears to be an under-diagnosed condition, with estimates of up to 50% of cases remaining unreported as they either go unrecognised or mothers fail to seek treatment through being in denialIf untreated, symptoms commonly resolve in six months but can persist for up to three yearsconsequences for mother and child

Early detection remains a challenge and relies on identifying those at risk, preferably during early pregnancy. Risk factors include genetic predisposition and environmental factors including social, psychological and biological, including nutrition defi cienciestools have been developed to enhance diagnosis. The Edinburgh Postnatal Depression Scale (EPDS) comprises a ten-item questionnairerepresents an easy to use screening toolrecently, a three-item subscale of the EPDS showed equivalent reliability at detecting PND which makes it an attractive screening tool for clinical useDepression Predictors Inventory revised to include questions around 13 signifi cant risk factors (see table opposite). PND symptoms are similar to those of depression at other times of life such as mood swings, sleep disturbance, change in appetite, poor concentration and irritability, and additionally mothers experience guilt about their inability to care for their baby

Table of risk factors

Risk Factor Mean r (correlation coeffi cient) effect size (Beck 2002)

Cohen’s effect size (Robertson et al 2004)

1. Prenatal depression 0.44-0.45 0.75

2. Childcare stress 0.45-0.46

3. Self-esteem 0.45-0.47

4. Prenatal anxiety 0.41-0.45 0.68

5. Life stress/events 0.38-0.40 0.61

6. Social support 0.36-0.41 0.64

7. History of previous depression 0.38-0.39 0.58

8. Marital satisfaction/relationship 0.39 0.39

9. Infant temperament 0.33-0.34

10. Maternity blues 0.25-0.31

11. Marital status 0.21-0.25

12.Social/socieconomic status 0.19-0.22 0.14

13.Unwanted/unplanned pregnancy 0.14-0.17

Obstetrics 0.26

Red = strong/moderate effect Pink = moderateWhite = small/moderate Yellow = small

Takenfrom:BeckcT(2002)RevisionofthePostpartumDepressionPredictorsInventory.Journal of Obstetric Gynecologic & Neonatal Nursing31:394–402

Robertsone,GraceS,WallingtonTandStewartDe(2004)AntenatalRiskfactorsforPostpartumDepression:aSynthesisofRecentLiterature.General Hospital Psychiatry26:289-295)

The causes of PND are likely to be multi-factorial, although it is suggested that 40-50% of the risk of depression is genetic, making certain people more vulnerable14. However, non-genetic factors are also considered important in gene expression, with environmental considerations such as stress, immune status and hormone imbalances creating profound infl uences.

The Impact of Stress and Disturbances of the HPA Axis Stress is considered a central component of mood disorders15. Pregnancy and birth represent signifi cantly stressful physiological events in themselves and additional physical stressors may occur at this time, including surgical interventions, post birth pain, sleep disturbances and exhaustion, nipple soreness and a lack of suffi cient nutrients, together with psychosocial factors. The brain reacts to stress by activating the

6 | OPTIMUM NUTRITION ENEWS | MAY 2011

Postnatal DepressionCOVERSTORY

hypothalamus-pituitary-adrenal (HPA) axis, resulting in the secretion of corticotrophin releasing hormone (CRH) which ultimately stimulates the release of cortisol from the adrenals14. During pregnancy, cortisol is released from the placenta and CRH levels show a 30-fold increase, which is thought to suppress adrenal production after delivery3. A sharp drop in CRH is noted at birth, with reduced cortisol release thereafter3. Pregnant women who go on to develop PND were found to have higher levels of CRH in pregnancy from 25 weeks onwards and longer suppression of CRH in the fi rst 12 weeks after birth16 and reported higher levels of perceived stress17. It is interesting to note that anxiety in pregnancy is a risk factor for PND and, in susceptible women, high cortisol may stimulate anxiety in pregnancy, while the sharp withdrawal of cortisol at birth is thought to trigger PND18. Additionally, high cortisol levels have been shown to reduce levels of serotonin19, a neurotransmitter known to induce feelings of happiness and wellbeing. Breast feeding appears to offer better tolerance to stress and helps to modulate the infl ammatory process20, 21. Stress can also stimulate the immune system to release pro-infl ammatory substances called cytokines, resulting in an increased level of infl ammation and a change in the immune cell balance21.

The Link Between Stress, Infl ammation and Immune DysfunctionActivation of infl ammation and neuro-immune interactions is thought to play an important role in the onset and maintenance of depressive disorders characterised by higher levels of pro-infl ammatory cytokines22. These are naturally elevated in the last trimester, are thought to help ripen the cervix before birth and play a role in uterine contractions, and continue to be elevated in the postnatal period. Indeed, levels of infl ammatory compounds are thought to be 40-50% higher in depressed people21. Elevated levels of pro-infl ammatory cytokines are known to induce ‘sickness behaviour’ with symptoms of altered sleep, loss of appetite, depressed mood, emotional emptiness, lack of energy, low sexual activity and reduced socialization, similar to those of depression21, 22. Increased infl ammation and immune activation are also shown to lower available serotonin by inducing the breakdown of its precursor tryptophan to produce neurotoxic and anxiogenic (anxiety-promoting) effects19.

The Impact of Sex Hormone Shifts Women are considered twice as susceptible to mood disorders as men24 and depression is more common at vulnerable times of hormone fl uctuation such as premenstrually, after birth, and perimenopause, so sex hormones are thought to play a direct role in perpetuating PND8, 3. It is well known that hormone levels change dramatically during pregnancy and at birth. By the third trimester oestrogen rises 50-fold, while progesterone increases ten-fold over maximum menstrual levels, dropping sharply immediately after birth to stabilise to normal levels within a week3. This sharp drop may have a direct effect on the functioning of the brain as oestrogen has been shown to regulate serotonin synthesis, receptors and transporters15, and exert neuroprotective functions25,26, while progesterone and its metabolites are shown to have anaesthetic-like properties in animals27. Although no clear relationship between hormone levels and risk of PND has yet been determined, hormonal fl uctuation seems to affect a small subset of sensitive individuals at the neurotransmitter or receptor level27. This is evidenced by a small study designed to mimic pregnancy oestrogen and progesterone changes in women with and without a history of PND. It found that 62.5% of those with a history of PND developed mood symptoms, while none were reported in the control group3. Some success has been reported for oestrogen replacement therapy2, while results with progesterone are mixed in their effect on PND28.

Role of Thyroid FunctionThyroid dysfunction may be a factor for an estimated 5-9% of pregnant women who develop thyroid abnormalities within six months of giving birth. 38% then go on to develop PND29,30. This condition manifests itself as a transient phase of hyperthyroidism followed by transient hypothyroidism which may become permanent in 30% women and is associated with the development of positive anti-thyroid antibodies30. The presence of elevated anti-thyroid antibodies has been associated with higher depressive scores31 and may be related to activation of the infl ammatory response, producing a state of malaise and depression27,32.

Antibody responses are to some extent suppressed during pregnancy, presumably to protect the foetus from rejection. This suppression may result in an autoimmune rebound phenomenon experienced after birth27. Reduced thyroid function may also affect PND by its association with reduced serotonin levels2.

7 | OPTIMUM NUTRITION ENEWS | MAY 2011

In conclusion, PND appears to result from complex interactions between the stress response, inflammatory and immune mediators, hormones, neurotransmitters and social and psychological factors. The common denominator across all these possible contributory factors is the nutritional status of the mother, as nutrition provides precursors and cofactors for biochemical pathways for the formation of stress, thyroid and sex hormones and immune mediators. Our next article will address how nutritional therapy can be of real benefit for the prevention and treatment of PND.

References1. Robertsone,GraceS,WallingtonT,StewartDe(2004)

Antenatalriskfactorsforpostpartumdepression:asynthesisofrecentliterature.General Hospital Psychiatry,26:289-295.

2. HendrickV,AltshulerLL,SuriR(1998)HormonalchangesinPostpartumandImplicationsofPostpartumDepression.Psychosomatics,39:93-101.

3. BlochM,DalyRc,RubinowDR(2003)endocrinefactorsintheetiologyofPostpartumDepression.Comprehensive Psychiatry,44:234-246.

4. coxJ(2004)Post-natalmentaldisorder:towardsIcD-11.World Psychiatry,3:96-97.

5. BeckcT(2002)RevisionofthePostpartumDepressionPredictorsInventory.Journal of Obstetric Gynecologic & Neonatal Nursing,31:394–402.

6. LeungBMY,KaplanBJ(2009)PerinatalDepression:Prevalence,RisksandthenutritionLink-AReviewoftheLiterature.Journal American Dietetics Association,109:1566-1575.

7. RamsayR(1993)Postnataldepression.Lancet, 342:1358.8. eppersoncn(1999)PostpartumMajorDepression:Detection

andTreatment.American Family Physician,59:2247-2254.9. coxJL,HoldenJM,SagovskyR(1987)DetectionofPostnatal

Depression.British Journal of Psychiatry,150:782-786.10.MccoySJB(2011)PostpartumDepression:anessential

overviewforthepractitioner.Southern Medical Journal 104:128-132.

11.ApplebyL,KorenG,SharpD(1999)Depressioninpregnantandpostnatalwomen:anevidence-basedapproachtotreatmentinprimarycare.British Journal of General Practice,447:780-782.

12.KabirK,SheederJ,KellyLS(2008)IdentifyingPostpartumDepression:Are3QuestionsasGoodas10?Pediatrics,122:e696-e702.

13.craigM,HowardLM(2009)Postnataldepression.Clinical Evidence[Online]PubMed(http://www.ncbi.nlm.nih.gov/pmc/articles/PMc2907780).Accessed:9thApril2011

14.nestlereJ,BarrotM,DiLeoneRJ,eischAJ,GoldSJ,MonteggiaLM(2002)neurobiologyofDepression.Neuron,34:13–25.

15.RubinowDR,SchmidtPJ,Meltzer-BrodyS,HarshVL(2009)GonadalHormonesinWomen.concentrationversuscontext.In:Hormones, Brain and Behaviour.2ndedn.,elsevierInc.5.76,p2395-2428.

16.YimIS,GlynnLM,DunkelSchetterc,HobelcJ,chicz-DeMetA,SandmancA(2009)elevatedcorticotropin-ReleasingHormoneinHumanPregnancyIncreasestheRiskofPostpartumDepressiveSymptoms.Archives of General Psychiatry,66:162-169.

17.GroerMW,MorganK(2007)Immune,healthandendocrinecharacteristicsofdepressedmothers.Psychoneuroendocrinology,32:133-139.

18.KammererM,TaylorA,GloverV(2006)TheHPAaxisandperinataldepression:ahypothesis.ArchivesofWomen’sMentalHealth,9:187-196.

About the authorsCornelia Dyball MSc DipION CNHC MBANT is a Nutritional Therapist working at Gaia Natural Health in Forest Row, East Sussex. Her web address is www.explorenutrition.co.uk Telephone: 01825 791209

Alexandra Rock BSc Hons ARCS DipION FdSc DipMktg is a Nutritional Therapist working at Back in Balance in Putney, London. Her web address is www.alexandrarocknutrition.co.uk Telephone: 07774 236599

19.MaesM,MihaylovaI,DeRutyterM,KuberaM,Bosmanse(2007)TheimmuneeffectsofTRYcATs(tryptophancatabolites)alongtheIDOpathwayrelevancefordepression-andotherconditionscharacterizedbytryptophandepletioninducedbyinflammation.Neuroendocrinology Letters,28:101-106.

20.GroerMW,DavisMW(2006)cytokines,Infections,Stress,andDysphoricMoodsinBreastfeedersandformulafeeders.Journal of Obstetric Gynecologic & Neonatal Nursing,35:599-607.

21.Kendall-TackettK(2007)Anewparadigmfordepressioninnewmothers:thecentralroleofinflammationandhowbreastfeedingandanti-inflammatorytreatmentsprotectmaternalmentalhealth.International Breastfeeding Journal,2:6.

22.MaesM,YirmyiaRnorabergJ,BreneS,HibbelnJ,PeriniG,KuberaM,BobP,LererB,MajM(2009)Theinflammatory&neurodegenerative(I&nD)hypothesisofdepression:leadsforfutureresearchandnewdrugdevelopmentsindepression.Metabolic Brain Disease,24:27–53.

23.SchröcksnadelK,WirleitnerB,Winklerc,fuchsD(2006)Monitoringtryptophanmetabolisminchronicimmuneactivation.Clinica Chimica Acta,364:82-90.

24.GjerdingenDK,YawnBP(2007)PostpartumDepressionScreening:Importance,Methods,Barriers,andRecommendationsforPracticeJournal of the American Board of Family Medicine,20:280-288.

25.finkG,SummerBeH,McQueenJK,WilsonH,RosieR(1998)Sexsteroidcontrolofmood,mentalstateandmemory.Clinical Experimental Pharmacology & Physiology,25:764-775.

26.ShepherdJe(2001)effectsofestrogenoncognition,MoodanddegenerativeBrainDiseases.Journal American Pharmaceutical Association, 41:221-228.

27.HarrisB(1996)Hormonalaspectsofpostnataldepression.International Review of Psychiatry,8:27-36.

28.DenniscLe(2004)PreventingPostpartumDepressionPartI:AReviewofBiologicalInterventions.Canadian Journal Psychiatry,49:467–475.

29.PopVJ,deRooyHAM.,VaderHL,vanderHeideD,vanSonM,KomproeIH,essedGGM,deGeuscA(1991)PostpartumThyroidDysfunctionandDepressioninanUnselectedPopulation.New England Journal Medicine,324:1815-1816.

30.LazarusJH,PremawardhanaLDKe(2008)PostPartumthyroiditis.InWeetmanAP,Autoimmune Diseases in Endocrinology,p177-192.

31. McCoy SJB, Beal JM, Payton ME, Stewart AL, DeMers AM, Watson JH (2008) PostpartumThyroidMeasuresandDepressiveSymptomology:APilotStudy.Journal of the American Osteopathic Association,108:503-507.

32.HarrisB,OrettiR,LazarusJ,ParkesA,JohnR,Richardsc,newcombeR,HallR(2002)Randomisedtrialofthyroxinetopreventdepressioninthyroid-antibody-positivewomen.British Journal of Psychiatry,180:327-330.

Postnatal DepressionCOVERSTORY