Diet and Maternal Mental Health

This 2020 systematic review investigated whether the mental health of pregnant women may adversely affect their diet or the inverse: that poor nutritional intake during pregnancy may predispose women to mental health issues. Thirteen peer-reviews articles published between 2000 and 2018 evaluating the relationship between antenatal and postnatal depression with dietary intake were included in this review. Of these, five were cohort studies (including two birth studies) and eight were cross-sectional studies accumulating data from a total of 12,742 individuals. The studies were split into five groups based on what they analyzed: nutrients, micronutrients, dietary patterns, dietary behaviors, and intake of fish and vegetables. The “Healthy Eating Index” was inversely associated with maternal depression, while deficiencies in calcium, iron, and folate were all found to be associated with maternal depression. Studies exploring the association of depression with dietary patterns found a protective association of "Health Conscious", "Healthy," and "Brazilian" dietary patterns with maternal depression. In a diet behavior study, predictors of depressive symptoms in the late postpartum period (after childbirth) were found to be prenatal (before birth) and early postpartum eating attitudes and BMI. The authors conclude that lifestyle risk factors could be an important contributor to maternal depression.

This 2019 systematic review aimed to assess the evidence for the association between dietary patterns with perinatal anxiety and depression (PAAD). The ten studies included in this review (of which six were cohort and four were cross-sectional) were deemed to possess good methodological quality using the Newcastle-Ottowa Scale (NOS). The following dietary patterns were examined in these studies: the Western (10); healthy (9); and traditional (7). The healthy pattern was inversely associated with prenatal and postpartum anxiety and prenatal depression. Although no significant association could be found between Western diet and PAAD, the traditional Japanese dietary pattern, the traditional Indian-confinement dietary pattern, the United Kingdom traditional dietary and the traditional Brazilian dietary pattern were associated with a lower risk of prenatal depression, postpartum depression, prenatal anxiety and postpartum anxiety, respectively (although the quality of evidence is suggested to be very low to low). The authors conclude that while the healthy dietary pattern was negatively linked to PAAD, further studies will be required to better evaluate associations between dietary meal patterns and PAAD.

In this 2015 prospective cohort study, Vilela et al. examined 207 healthy pregnant women in Brazil to determine if there is a correlation between pre-pregnancy dietary patterns and variations in anxiety symptoms from mid-pregnancy to early postpartum. The women were examined at 5-13, 20-26, and 30-36 gestational weeks, and once at 30-45 days postpartum (tests included State-Trait Anxiety Inventory to evaluate anxiety symptoms and food frequency questionnaire for dietary intake). The subject population could be divided based on their pre-pregnancy dietary patterns: common-Brazilian (mainly rice and beans); healthy (mostly fruits, vegetables, fish and tea); and processed. The mean anxiety symptom scores for the second trimester, third trimester and postpartum were 40.4, 40.5, and 37.2 respectively. When accounting for gestational age, the rate of variation of the State-Trait Anxiety Inventory score was 0.535 (95% CI -0.035 to 1.107; P=0.066). Statistically significant evidence was found negatively linking both the common-Brazilian (p=0.021) and healthy eating pattern (p=0.029) with prospective changes in anxiety. The researchers conclude that high adherence to the common-Brazilian or healthy dietary patterns was negatively associated with higher anxiety symptom scores from mid-pregnancy to early postpartum in this group of Brazilian women.

This 2020 systematic review retrieved data from existing studies (search ranging from 1835-2020) and examined the association between maternal postpartum diet and postpartum depression (PPD). Of the 931 relevant articles identified, six met the eligibility criteria, of which four were cross-sectional and two had a cohort design. All but one study found at least one inverse association, linking greater adherence to a healthy diet during the postpartum period with fewer PPD symptoms. Although the researchers state that further longitudinal and intervention studies are needed, a balanced maternal diet with a focus on fruits, vegetables, fish, grains, legumes, and herbs is suggested to possibly reduce the incidence of PPD. This review provides evidence that the postnatal diet could have an effect on postpartum depression symptoms.

Past research in non-pregnant and pregnant populations suggests that depression may influence diet during pregnancy, which has a significant impact on the health of both mothers and their children. In this 2020 study, Avalos et al. investigated the relationship between prenatal depression and diet quality during pregnancy overall and by race/ethnicity. It also explored the correlation between prenatal depression and the 12 dietary components of the Healthy Eating Index 2010. The researchers provide a secondary analysis of a cohort study of Kaiser Permanente Northern California women (1,160 pregnant participants) entering prenatal care between October 2011 and April 2013. One-hundred and fifty nine (14%) subjects were found to suffer from prenatal depression. These women were two times more likely to have diets of poor quality compared with women without prenatal depression after adjusting for potential confounding variables. Women with prenatal depression consumed more empty calories (solid fats, added sugars, alcohol [p = 0.01]), fewer greens and beans (p<0.05), fewer total fruit (p<0.01), and whole fruit (p<0.01), compared with those not depressed while pregnant. Differences emerged by race/ethnicity as Hispanic women with prenatal depression were 166% more likely to have poor diet quality compared to Hispanic women without diagnosed depression. These findings suggest that women with prenatal depression are at higher risk of having a poor diet compared with those without prenatal depression, and the relationship is more prominent among Hispanic women. The authors suggest that nutrition counseling interventions for women with depression may be helpful. These should include consideration for different cultures and target limiting empty calories from solid fats, alcohol, and added sugar, as well as encouraging the consumption of greens, beans and fruits.

In this 2018 study, researchers aimed to characterize dietary patterns during the “confinement period” (the first month after giving birth) and then examine their associations with postpartum depression (PPD) and anxiety (PPA). Three-day food diaries recorded dietary intakes of 490 women in the first month postpartum, and at the 3-month postpartum mark, participants completed the Edinburgh Postnatal Depression Scale (EPDS) and State-Trait Anxiety Inventory (STAI) to indicate depressive and anxiety symptoms (higher the score, the more symptoms). Four dietary patterns were identified: Traditional-Chinese-Confinement diet, Traditional-Indian-Confinement diet, Eat-Out diet, and Soup-Vegetables-Fruits diet. The Traditional-Indian-Confinement diet was associated with less PPD symptoms and showed a non-significant link with reduced probable PPD, and the Soup-Vegetables-Fruits diet was associated with fewer PPA symptoms. The findings therefore included adherence to the Traditional-Indian-confinement diet (composed of herbs and legumes) and Soup-Vegetables-Fruit diets (high in fruits, vegetables and fish) during the postpartum period were associated with fewer PPD and PPA symptoms, respectively.

This 2019 study recruited 1,659 participants from Tianjin, China. The researchers assessed the participants’ diets using food frequency questionnaire, as well as their depressive symptoms at 6-12 weeks postpartum (after giving birth) in order to investigate the association between dietary patterns and incidence of postpartum depression among Chinese women. Six dietary habits were identified among the pregnant women: beverage, vegetable, cereal-meat, nut-fruit, egg, and seafood patterns. The highest tertile (T3) of the nut-fruit pattern was significantly associated with reduced risk of postpartum depression (OR = 0.74; p = 0.02) while the T3 of the seafood eating habit was also associated with fewer incidences of postpartum depression (OR = 0.753; p = 0.033). This present study therefore found that an adequate dose of fruits, nuts, and seafood is important for postpartum women in China.

In this 2011 study, Chatzi et al. retrieved data from the prospective mother-child cohort ‘Rhea’ study set in Crete, Greece between 2007-2010 (529 female participants). They sought to identify and describe the dietary patterns of the pregnant women and investigate whether dietary habits during pregnancy were related to postpartum depression. The Edinburgh Postpartum Depression Scale (EPDS) was used to examine depressive symptoms at 8-10 weeks postpartum. During pregnancy, the participants completed food frequency questionnaires, which were used to identify two dietary patterns: ‘health conscious’— characterized by vegetables, fruits, pulses, nuts, dairy products, fish, and olive oil — and the ‘Western’ eating pattern. High adherence to a ‘health conscious’ diet was associated with lower EPDS scores (highest vs lowest tertile; p = 0.02). Women in the second or third tertile of the ‘health conscious’ dietary pattern were about 50% less likely to exhibit a high number of PPD symptoms (EPDS ≥ 13) compared with those in the lowest tertile. Additional longitudinal studies and trials are warranted to support these findings, but the researchers conclude that a healthy diet during pregnancy is associated with a decreased risk of developing postpartum depression.

In this 2014 study, Vilela et al. sought to identify dietary patterns before pregnancy and examine their association with depressive symptoms suffered during pregnancy. The researchers examined 248 healthy pregnant women in Brazil at 5-13, 20-26, and 30-36 gestational weeks. Dietary intake was recorded through the use of food frequency questionnaires (between 5-13 gestational weeks) and depressive symptoms were evaluated during three follow-up points using the Edinburgh Postnatal Depressive Scale (EPDS). Three prepregnancy dietary patterns were identified: common-Brazilian, healthy, and processed. The healthy dietary pattern was inversely associated with depressive symptoms (p = 0.011). Mean depressive symptom scores were 9.0 (95% CI: 8.4, 9.6), 7.2 (95% CI: 6.5, 7.8), and 7.0 (95% CI: 6.4, 7.7) for trimesters 1, 2, and 3, respectively. This current study found that high adherence to the healthy dietary pattern before pregnancy was associated with lower EPDS scores during pregnancy in Brazilian women.

Nutritional deficiencies and maternal depression: associations and interventions in lower and middle-income countries: a systematic review of literature