Hope you all guys had a good breakfast, a healthy one, because that's what we're talking about today. And after this, I want to motivate you all to have a healthy lunch, too, and continue on the path of health. You might be wondering, what is gastroenterosarchiatry? And believe me, I'm going to start with the topic first before I tell you who I am. It's going to be a little bit turned around. So gastroenterosarchiatry was something I had been googling for a while and not finding anything. So officially, I cannot take credit for the term. Unofficially, I can, because I couldn't find anybody else using the term. However, that's where now is the crunch. What is gastroenterosarchiatry? Why the long name? And I'm going to stop here and introduce myself. I'm Dr. Bhagwan Bharu. And I have three of my colleagues here, who were also my colleagues two years ago when we did a similar presentation, not the same. That was 101. This is 102. And that, unfortunately, could not be live because of, you know, pandemic. So it went to on-demand. And the demand was so good that it became, some of you might have remembered or not, if you have the memory of an elephant, you would. And that is last year, January 2022. Anybody remember what the CME course of the month was? I don't think so. It's been a year and some months. But yes, it was us. Thank you. So that presentation, which went straight to video because of the pandemic, became a hit and became the CME of the month. That encouraged me to explore it further. The guys were not available. So three other residents joined me, residents at that time. Now they are not. One of them is not. And we have another presentation because they were also encouraged. They said, why should these guys get all the credit? We need something, too. So we have another presentation on Tuesday, 345. Different subject, same topic. So they're all follow up. So we have four presentations for you on this topic. Now, coming to what the topic is, it's a topic that has often been not given due importance in our mental health work. And that is where we are going to talk about today. The opinions in this are all picked up from the internet, but they're all ours. Nobody else is going to say we have anything against or for it. And the four speakers, we have no relevant financial relationships to disclose. What are the learning objectives today? As I mentioned, we have taken a step up from what we did a year and a half ago. And that is we're going to talk today about the complexity of the microbiome and what happens as the person is developing in age, all the way from newborn to elderly. We're also going to talk about nutraceuticals, about how some of the multivitamin therapy is found to be beneficial in people diagnosed with ADHD. We're also going to talk about one other nutraceutical called NAC. And finally, I'm going to turn the topic around and talk about the phenomenon of food desserts and why it's important not only to be motivated to eat good food, good food should be available. And finally, what is the government doing about it? These are today's agenda. Technically, I'm supposed to get only five minutes, but I can't finish in five minutes. So I'm going to steal some of the minutes from them. And that's why it might run into maybe seven, eight, or nine minutes. And I will introduce each one as we go along. That's me. All right, so my discussion has more slides than I have time. I have about 20 slides. These are for your benefit. You know you can easily download them on your phone and see them at your leisure. They're also very dense as far as text is concerned. I cannot possibly even read through the text in five minutes. So take your time. Today, I'm introducing this to you because it's a concept that is worth discussing. Lots of quotes have been attributed to Hippocrates. I cannot believe one person was so wise and had so much time to talk about things. But anyway, it is what it is. They may have been his assistants or others who might have said things. Bottom line, he was a big proponent of gastroenterosarchiatry. He just didn't use that term. And as you can see, sometimes some of the attributes are such that they're saying, hold off the medications. Try food first. I'm not going to say that. I'm going to say, do them side by side. It's better to tackle it directly than wait for the food response to happen. All right, so what is microbiome? And Dr. Thanh Nguyen is going to give you much more details about it. I'm just giving you a bird's eye view. How many zeros in trillions? Plenty, right? And there are hundreds of trillions of them in our body. We have even been told there are more of those things in our body than our original cells. Go figure. So we are only partly human. And what are these microorganisms? And why are they there? And what are they doing for us? All different types, prokaryotes and eukaryotes. And there are some viruses in between. They colonize our gut. Plenty of seats in the front. Please come in. They colonize our gut. They interact with our immune system. What could be better than that? They are the ones who should be blamed if any immune system goes wrong. And they should also be praised if things go right. And we have come to the conclusion, the scientists, that the microbiome plays a huge role in our mental and physical health. One body, one mind. Don't ever forget that. There is no dichotomy of systems. And as we'll see, even the systems all come together. What are the functions of the gut microbiome? These are just a few of the many. Bottom line, they are so vast and go all over everywhere, such that their influence has often been called as a new organ system, separate from every other organ system in our body. What is their influence? You could call them directly as the bidirectional brain-gut microbiome. That would not do justice to this entity, because they also affect endocrine, neurological, as well as immunological systems. Oh, by the way, one important thing. The immune system depends on the gut microbiota for its normal development, whereas the gut microbiota depend on the tolerability of the immune system for its survival. And you might be wondering, are we in the wrong place here? He hasn't talked a word about psychiatry. All he's going on and on about immune and microbiome. Believe me, it'll all come together. So the pathways, many different pathways. But if you go online and search, you will find something called PNEI. PNEI is a very important axis in our body, which we should all pay attention to. Psycho, neuro, endocrine, immunological system. So even though microbiome deals with the immune system and the mental health, it also affects all other systems, too. In fact, food tolerances, autoimmunities, atopies, various neuropsychiatric conditions, so far as even Parkinson's disease has been blamed on these, of course. Depression, schizophrenia, all of that, too. I'm not saying they're direct influencers, but they do affect and influence. And we can use that influence to our advantage when we are managing patients. Here is one little diagram of how stress affects the HPA system, all the way down to creating metabolic syndrome and cardiovascular systems. I met an old colleague of mine today who was talking about insulin resistance. And I said, please do come in to this talk. You will get to know some idea of what insulin resistance is. I don't know if he's here. There he is, waving his hand. So that was the immune part. I hope I have not bored you too much, just motivated you enough. Because now I'm going to change the topics and talk about food, our favorite subject. We live to eat, or we eat to live? I am both. And I hope each and every one of you is, too, because that's the best balance you can create. Diets have changed over time. We all know that. It's not a rocket science to know that what 10,000 years ago people were eating, they're still eating. We would think it's progress. We don't know if it is or not. And the microbiome has also evolved in those 10,000 years. Because that was a time when they went from paleolithic period to farming. And the diet changed to high carbohydrates, because now they were farming all the grains, ancient and modern grains, rice, wheat, barley, and others, pellets. And then something else changed about 200-plus years ago. The industrialized age came up. And here we have a problem, because now things started getting processed. Nature never meant for us to process foods the way we intend to today. Of course, very easy. Just go down the block and get a takeout. What could be better than that? Who wants a slog in the kitchens anyway, right? Maybe I've offended somebody here. All right, I'm sorry if I did that. But bottom line is, food today is also one more important thing, sterilized. So the bacteria and all the other microorganisms which one day were helping us are now being taken out of the equation. And that's where we need to know, because is the gut microbiota keeping up with that change? What are the factors that influence the microbiota? Quite a lot. I'm going to skip this one for the sake of time. Mode of delivery is another important aspect that we should all know, vaginal versus caesarean. What happens? Caesarean is sterile. Vaginal is full of those bacteria that are passing into the gut of the newborn. A big difference. Does it stay for long? Probably not. Because what happens is that nature creates a kind of a balance. They say, we cannot put this person to a disadvantage. So the only disadvantage that has been seen is sometimes the allergies are more in those who have been born by C-section. All right, I guess you can find one person in that picture. You can see, right? Yeah, that would be me, my wife, my son, his wife, and the two grandkids. Why did I put that picture there? Just for self-glorification? No, I wanted to raise an important point. And that is, throughout the lifespan, the microbiota change. And hopefully, the change stays with us in a good manner, unless things go wrong. So by the age of three, the child is pretty much having the same microbiota that the person will have for the rest of their adult life. Quite stable, right? Unless we insult it by antibiotics. You know what antibiotics do. They kill good and bad. Equal opportunity abuser. I think abuser is the wrong word here. Never mind. All right. In the elderly, of course, also remember, even monozygotic twins do not necessarily share identical microbiome, what you eat. And I'm going to jump to the other activities we do in the next few slides to tell you how we change it. In the elderly, of course, by the way, the antibiotics and also sometimes people start eating differently because of convenience, availability, et cetera. Of course, it's a no-brainer when we say the diet influences our gut microbiome, what we eat. Somebody coined that term, right? We are what we eat. I think now is the time to use that. So again, as I told you, very high-dense information. I cannot read all of that. It's for you to read or discard. But bottom line is there are many changes that occur, even on a day-to-day basis. And that has been known to reverse because somewhere along the line, nature creates a balance. Fermented foods. How many people are up for fermented foods here? Raise your hands, please. Oh, wonderful. I have a wonderful audience, I tell you. Everybody's up for it. Every culture has fermented foods. And I've never up till now figured why. Because all the ancient cultures knew exactly what it did to the body and to the mind. The best thing about it is they provide you direct source of, what is it, prebiotics or postbiotics? Somebody will explain more. I'm leaving that question for you. Though now we have come up with a new term, symbiotics. They also affect the immune system. The guys are looking at me. I'm way over my time. US immigration, the ideal. We all live the American dream. Unfortunately, sometimes some of that part of dream becomes a little bad. Most of it is good. I am living that American dream, too. However, I am still using the same diet pattern I did way back when I grew up in India. So that has kept me in sort of a good mental health, I should say. Otherwise, do you know what the American diet is called? What's the acronym? SALAD. SALAD. There you go. See? You're well versed of it. I don't even need to tell you about it. Where does the S come from? Standard American diet. Here is something for a take-home message. Meditation and microbiota, a very recent study. It was just published early this year. They found out, they did a controlled study, and they found out that the Buddhist monks in Tibet had a much healthier microbiome than the control group. Was it diet? Was it meditation? Or was it a combination? They also had less of cardiovascular disease, by the way. Sleep, another big important factor. As I told you, the biome is influenced by multiple ways. One of them is with sleep. Exercise, all things we tell our patients, right? As providers, have a good sleep. Eat well. Exercise. Do meditation, even some yoga if you want. We forget to tell them, eat fermented foods. I hope you will remember that when you go back, along with other things that we are saying. Here is another interesting thing. You have a cat or a dog at home? Your gut microbiota is going to change. Not for the good, not for the bad. It just equalizes. However, there are some reports where people with pets have less of allergic conditions. And even metabolic disorders are less. My grandkid is telling me, I have to have a cat. I told her, the day you are responsible enough to take care of the cat, you shall have her. All right. I'm going to leave you with this last slide. As you know, there are plenty of food classifications all around. This is just one particular slide that tells you how we go from the very healthy to the less healthy group. All right, so group one is the healthiest. And as we go up the numbers, the health part goes a little bit less and less. On that note, I am going to hand over. These are my references. I'm going to hand over to Dr. Tan Nguyen. And he's going to talk more about the good stuff. Please welcome Tan Nguyen. Thank you. Hi, everyone. My name is Tan Nguyen. My adult patients called me Dr. Nguyen. My supervisor calls me Lieutenant Nguyen. And a lot of my child patients called me Mr. Nguyen. And today, you can just remember me as that guy who talked a lot about all of your trillions of friends in your stomach today. So I kind of want to start with this idea that I'll lay a lot of the foundation of, I guess, what my colleagues are going to talk about afterwards. We've got a 10,000 foot view. We'll start in the gut. And we'll work our way up to, well, kind of the meat of the conversation, about like nutraceuticals, how the microbes are affected by the food that we eat. But more importantly as well, how that relates or interfaces with psychiatry. And then we'll end with this obviously non-contentious conversation about how the system may or may not be affecting that. And by that, I mean society. So on that note, this is the one thing I hope to deliver today. And that's to illustrate and if not give you guys an appreciation of some of the complexities of the microbiome. Not that you guys thought that it was easy to begin with. Or maybe if you do, you're a lot smarter than me about that. The one thing I do want to go over more than anything else is ensuring that semantics are, you know, we're all on the same page for that. Excuse me if I have this kind of a little bit more childish of a metaphor. But this is how I use primarily my child and adolescent clinic. So we're going to go over microbiota, microbiome. And I usually think about that in regards to like a town more than anything else. So if the microbiome is the population within the town in itself, microbiota is where the town is located. So you can imagine the environment in St. Paul, Minnesota might be a little bit different than like Pensacola, Florida. As well as the people there, the microbiome might be different as well. However, the other part of the microbiome, the definition behind that, is not just the bacteria. We're thinking about the fungal, the viral, as well as the protozoans. I'm not going to bore you guys with RNA gene sequencing. I assume you guys already know all about that. But it's actually the accumulation of all of that when you talk about the microbiome. So think about that a little bit more about like the fingerprint of what all the microbes are in that specific environment or the microbiota. And then when you talk about microbiota diversity, it's actually looking at, well, the results of what that 16S RNA gene sequencing looks like. Who's there? Who's not there? What viruses are maybe infected in one part versus another part? In the town analogy that I'm using, these are actually the professions that you have in the town itself. Your firefighters, your police officers, your doctors, those that clean the streets. And you know, in St. Paul, Minnesota, where I'm from, you might want those that are very good at shoveling snow off the streets. Otherwise, if not, you can get into a little bit of a dysbiosis. I call those snow days. Those are my favorite, where things probably don't move as much. Or maybe things have gone awry, and we're trying to get back to a certain symbiosis. And I think, you know, Dr. Baru pointed out a very good point that sometimes it's not even the environmental things that happen. Sometimes it's iatrogenic that causes the dysbiosis, whether it's food or even medicine. So risk benefits all the time. Those are definitions just for now. You're wondering, OK, so why does this matter? If you think about it evolutionarily, one of the first nervous systems to be created is actually lined along our gut. And I think a lot of it has to do with our input and output and knowing what's toxic and knowing what's not toxic. But you know, our consciousness lives in the brain. So we're going to consider that our first brain. And our second one's going to be our stomach. I like to say that because, you know, it has its basically kind of mind of its own. You guys ever had that gut feeling when the butterflies come about? Usually that's a signal for the rest of your consciousness to say that, hey, something's going on. But my question becomes, like, why does that happen unconsciously? And I think a lot of the autonomic nervous system that is intact in our stomach with our trillions of friends of microbes might have something to do with that. And if the interface there is quite, I guess, intimate, I think that's an area that we probably shouldn't ignore. Not that you guys are ignoring it by being here. But one of the things that I do want to think about is whether or not we're thinking about that probably with our younger population. I don't have as cute of a picture in regards to talking about the generations as Dr. Beru. This is just a stock photo, that is not me. But when you think about it, the youth, from what I've read and from a lot of the references that I've looked into, are a little bit more susceptible in regards to dysbiosis. So when it comes to diversity, Dr. Beru already mentioned it, but something as simple as whether a spontaneous vaginal delivery versus a C-section dictates that. Stability over time, all will depend on the environment and the food that they will eat. And then the immune system interaction. One thing that I found quite interesting in the microbiome is that it's like teaching, that the microbes are teaching the nervous system in our gut more than anything else to know what's friend or foe. You can imagine a more overreactive, or I call it a more anxious gut, might be more inclined to come up with more autoimmune items or pathologies. That's more than anything why I think this conversation, at least in the youth, is worthwhile. Big questions I want you to think about as well as I'm going through this. Hopefully I've convinced you, at least on the first one, right? The second one, I think I wanna have a little more of a discussion as to what can actually, what we can actually do or what the action points potentially are based on this talk. And then why this topic has become a little bit more relevant now. I think a lot of it has to do with kind of going back to SAD or the American diet being looked into a little bit more as maybe not the best diet. This is an overview of the five points that I wanna talk about functionally with the microbiota. I put it, I call it in marine terms. So it feeds us, protects us, nurtures us, regulates us, and keeps us sharp. So when I'm talking about feeds us, right, we're not actually digesting the microbes. The microbes are digesting the food with the byproducts that actually helps us later on. Those being vitamins, whether it's vitamin B12, biotin, if not, maybe some of the dietary fibers as well. That protects us, I kind of already touched on a little bit where it's helping train the, I guess, the lymph system in the gut to know what's friend or foe. It nurtures us, vitamins, I already mentioned that, regulates us, there is a component of insulin resistance versus sensitivity and how much that correlates with the American diet. Then there's this very interesting area where it actually helps us develop neurologically as we're growing up from toddler, child to adolescent to a young adult. References are on the bottom and hopefully some of the bolded items are coming through. So I have not found a paper that talks about the microbiome without talking about short-chain fatty acids, right? So short-chain fatty acids you will see over and over again when it comes to part of the role as well as the byproducts that come from it. So what are short-chain fatty acids? They come from dietary fiber as well as sometimes carbohydrates, but there are three byproducts that come about from that. I call them BPA, butyrate, propionate, acetate, and one, well, a lot of the evidence in the parentheses are the ones that we're saying that it helps with more than anything else. It is ubiquitous, it is everywhere. And it's something that you definitely cannot ignore and I actually have found some very interesting papers that talk about short-chain fatty acids as well as this correlation of eating fermented food as well. How it potentially keeps a good symbiosis if you were to have a little bit heavier in that. This is interesting, but does anybody know why sometimes say like tomatoes are paired very well with say olive oil? Someone has to know this. No? No micropollan readers? All right, so the reason why is that the lycopene from the tomatoes itself are better absorbed if not the vitamin A and is helped with the olive oil. And usually that pairing, well, not only is it delicious, right? But more than anything else, that system that you introduce into the microbiota has a function of absorption itself, right? So when we think about things like single nutrients that we're always trying to isolate outside of its context, right? I sometimes, yes, that can be good, right? In terms like very isolated vitamin deficiencies, that can be good. But when you take it out of context and not understand the context, I would argue that we're shooting blind in the dark then if that's the case. So I guess my point there is be careful of the context that you take nutrients out of. So olive oil, tomatoes. As I mentioned before, the lymphoid system that it trains is quite interesting. A lot of that has to do with the CD4 plus T cells as well as the IgA production within the lymphoid system. So obviously if the T cells there as well as a lot of the immune receptors are being exposed to say, maybe a diverse or a variety of microbes, it probably is able to train itself a little bit better to become less reactive when it encounters something that it does not know, right? So if you're eating Cheetos every afternoon after school like I did, that probably would not lead to the most diverse immune system to be under reactive. But they were a dollar at the corner store, right? When you look on the back or the side as a calories, that has to be good. The other obvious immune function that it has is that it acts as obviously the barrier between say, well, your internal system as well as kind of this outside system in the colon. Sometimes that can be a little bit dissipated and that really depends on inflammation. And I think you guys might've heard the term leaky gut before. And that definitely can play into translocation of bacteria. And that's one of the most interesting things I remember about saying, if you have a dental procedure, inflammation can come about and if you take antibiotics, right? A lot of that has to do with kind of the translocation of bacteria into the blood. Outside of that, I think those were the probably the big points with the immune function. I mean, and then obviously because of the colonization of your trillions of friends in your stomach, it doesn't leave much space or it directly competes with other microbes that might want to grow in a certain area, right? So it's the towns folks being like, no, no, no, this is our place. Vitamin synthesis is interesting as well. A lot of that has to come with the short chain fatty acids that I've mentioned before. But this isn't as strong of a signal and I think there's only one isolated signal from my research in the Middle East about those that have a little bit more diverse or something a little bit more akin to like the Mediterranean diet and a higher proportion of vitamin B12 being produced in their stomach. Reading kind of the methodology of that was a little bit confusing for me, but there is a signal out there for that. That's the only slide that I have for this. I'm not gonna spend too much time on this. And then insulin sensitivity and protection as well as sleep correlation has to do with the hormonal umbrella of this. So the sleep correlation is probably the most interesting one that I kind of wanted to highlight. If you guys remember the diagram that Dr. Baroo brought up, it was IL-6 that was the direct correlation between that inflammation as well as keeping you up at night. So depending on how reactive or underreactive your gut can be or how you've trained it throughout development, there's this weird connection of IL-6 and then ultimately sleep as well. Correlation, not causation, interesting in itself. And then the brain function is the one that I think more than anything else, as this is being developed, it's getting closer and closer to this idea about how it can affect our mood, our neuronal development throughout childhood as well as our development. So not only is it kind of developing that autonomic nervous system in our stomach, but a lot of that has to do with the signals and cues about how it signals when neurogenesis can happen, when myelination can happen, both in your peripheral as well as central nervous system. But also this idea about how intact your blood brain barrier can be and when that's potentially going to be formed. A lot of that generally is formed around age 15 to 20 where a lot of that begins to plateau. But before that, a lot of that is being developed, whether that is obviously your environment, but in this case, food. So to go back to my idea here, after you've learned about all those five functions, hopefully there's a good illustration, if not appreciation of the idea of a susceptibility that can happen if we don't pay attention to what we feed children's, toddlers, and growing adolescents. I think it matters, and I don't think we give enough credence to it. Maybe the French do, because I've seen their diets in school and I am jealous every single time. But there is usually a good correlation between the two. You know, there's this one reaction to those that are on the American diet versus, say, those that live in the French culture diet. If you were to ask them what they first think about when they are asked to, hey, let's go have a slice of chocolate cake, what do you think the American diet, or the American on the American diet responded like? They actually say, that's too many calories, I'm on a diet. And so they're mindful of that, and what do you think the French said? Ah, there must be a celebration, right? So context, more than anything else. Why they're more worried about the social situation, why we're more worried about the nutritional, right? So context, more than anything else. We're more worried about the nutritional, right? So there's a little bit of a difference in both of the focus there. I think I've beat this pretty well. The last signal I wanna bring out is the signal I found about potential microbiome that exists in what we thought to be a more sterile environment in our CNS. I'm not saying that if you did a lumbar puncture you'll be able to grow things. A neurologist would probably just turn in his sleep right now. But there is a very interesting idea about microbiome that lives in very particular parts within our brains. The one that this study has talked about more than anything else, usually has to do with the studies about, I believe it was meningitis, and a certain microbiome that has caused the pathology and those that have not. But I think it's a good proof of concept to say that, hey, if we can get that much closer to the brain, the microbiome is just that much more of a conversation to have when it comes with psychiatric conditions or that field itself. This is an overview. That is my dog. And I bring him up there because I'm pretty sure we share the same microbiome more than anything else. And there is evidence on that. We'll talk more about that later. These are my references. Oh, sorry. I wasn't gonna talk about that slide to save some time. My references. And coming up next, again, we're expanding just a little bit more. We're gonna now talk about nutraceuticals and supplements in the youth. And my good colleague, Dr. Gutierrez, or Lieutenant Commander Gutierrez, will talk about that. So let's welcome him up. All right. Hello, everybody. So my colleague, Dr. Nguyen. So we're both child psychiatry fellows at Walter Reed. We get to spend a lot of time together. And this is a topic that is important, seeing kids today and getting an understanding of how their diet can impact their mood and their behavior and why it's important to talk about it. And also, being a father of four, even in our household, I see where there are deficiencies in our diet. And so it's my hope with them that we can shore up some of those deficiencies with some of the over-the-counter interventions that are available. And so in this time, we'll run through quickly about probiotics. We'll also spend some time discussing multivitamins. And then we'll finish off talking about N-acetylcysteine and get a little bit more into the details of its mechanism of action and what it's doing in our body. And so probiotics, they are everywhere. The global market this year is expected to reach $70 billion. But it's not something that's new. If you look, 1,700 years ago, there was a Chinese researcher, Ji Hong, who had a recipe for yellow soup. And he used this to treat very severe cases of diarrhea. And in that soup, he used fermented human fecal material. But if you fast forward to today, he wasn't all that off. We have fecal microbiota transplantation as something in medicine. It's something that is used in C. diff infections. And so luckily, we don't have yellow soup anymore. But over the last 50 years, there's been more emphasis on studying the different bacteria that exist in our microbiome. And if you look, just in 2021 alone, there were over 5,000 results in PubMed if you just type in probiotic. Can I see that? Okay. There. All right. So probiotics, the term was actually first defined by Lilly and Stilwell in 1965. They were doing work with protozoa, and they found that one specific species of protozoa increased the growth of another species, and they termed the coin probiotic. So today, there is an international association for probiotics and prebiotics, and they've issued their consensus definitions for both. And so probiotics are living microorganisms that must be ingested in sufficient amounts to have a positive effect outside of just the nutritional component that it provides. Prebiotics are substrates that are selectively utilized by certain species within our gut. And so these are things like oligosaccharides. Inulin is another one that's very popular. And then there's also Symbiotics, which is relatively new. And the Symbiotics are just a combination of the two, the probiotics and the prebiotics in one packaged product. But not every Symbiotic product out there is effective. It has to be something that the probiotic is going to use within your system. So in our gut, you can kind of consider our gut microbiome as the forgotten organ, kind of like a multicellular organ in our body. And like the lungs, the heart, the kidneys, it's something that we need to take care of. It's estimated that we have over 1,000 different species within our GI tract. And the four dominant phyla are the Firmicutes, Bacteroides, and Fibromycetes. And the Fibromycetes is the one that we need to take care of. The four dominant phyla are the Firmicutes, Bacteroides, Actinobacteria, and Proteobacteria. A large portion of this belong to the Bacteroides. As mentioned previously, we've co-evolved with the microbiome in our gut. And each one of us has a unique composition. And you can kind of consider it as like a microbial fingerprint. Now, when we zoom in on what we think is going on in our gut, we can kind of see at the epithelial level where there's an impact on, you know, from the resident microbiota that we have, the epithelial cells of our intestine, and the immune system. You know, the microbiota, they're classified into two different groups. There's the parietal. Those are the ones that live in the mucus or attached to the epithelial wall. And then there's the luminal. Those are kind of transitory. They come in with our food, and they leave with our stool. You know, the microbiota, you know, having a healthy microbiome can help prevent some of the more invasive and deleterious bacteria from taking root. There's also the different enzymatic pathways. So as it was mentioned before, the short-chain fatty acids, what they do is they help the tight junctions. So if you go all the way back to med school, to the GI clerkship, you know, when they talked about the tight junctions, those butyrate, propionate, it helps to strengthen that, preventing the leaky gut. And then there's also chemical signals produced by the microbiome that help with the immune system modulation. Now, when talking about what's on the shelf, you know, it was mentioned previously, and I was glad to see lots of people familiar with foods that are rich in probiotics. But, you know, on the shelf, you can find anything from single-species supplements to multi-species supplements. I've seen some with up to 10 or 20 different species within their product. But the important part is it has to have enough. And so typically the products have to contain at least 10 to the eighth to 10 to the 10th colony forming units for it to really have an effect. And that's so that the bacteria can make it to where we want it to make it as it transits through, you know, the very harsh environment of our GI tract. As more and more studies come out, hopefully we'll get a better idea of what species can have specific impacts in our body. And, you know, this diagram was taken from a review that was done in, you know, in the gastroenterology world. But they kind of break it down into a nice picture showing where the different bacterias have shown to have benefit, whether it's from the restoration of the epithelial barrier, inhibition of lipid accumulation, the anti-inflammatory profile, and the GLP-1 induction. And that's important because you may have heard of some of the GLP-1 analogs that are in the news like Ozempic and, what's the other one, Wigovi. So those are medications used in diabetes. They help control with insulin resistance and weight loss. And so maybe there's something a little bit more simple that we can do to help with the GLP-1 production. And so with kids, so this is important because, you know, especially in the child and adolescent population, I have several kids who have autism on my panel. And one of the hallmarks of autism is, you know, restrictive patterns. You know, when a kid only eats chicken nuggets from Chick-fil-A or McDonald's French fries, and that's the only thing they ever wanna eat, and parents have fought and fought and fought, and eventually kind of just given to keep the kid happy and get the kid nutrition and enough, you know, calories, it can be difficult. So what Logistica did, they did a systematic review that had seven different studies. One of the studies showed an increase in pro-social behavior in children with autism. And particularly, there was an increase in the lacnospirosae family in those studies. Prebiotic supplementation has also been shown to do something we expected, increase bifidobacteria populations in the youth compared to the controls. And the reason, they didn't see any maybe overt benefits in the rating scales or the behaviors, but one thing they did know was that the stools for those children were much easier to pass. And with some of the kids, I think of like quality of life, if it can be a little easier to get them in and out of the bathroom, then that's a win in my book. Also, an interesting one that I saw was supplementation from infancy up to the age of 13. One of the things that they found was that there was a decreased likelihood of developing ADHD and ASD in those patients who had the probiotic intervention from early on. And then another thing that was found was that vitamin D can actually modulate the gut microbiome. And that's something that is very common. The vitamin D deficiency, it's something that we talked about a couple of years ago in our presentation. And it's something that I check for pretty regularly in my kids and actually recommend pretty often for them to supplement those deficiencies. So other things to consider about the microbiome, they do play a role in neurotransmitter production. One interesting study in germ-free mice was that those germ-free mice actually required continuous supplementation of both vitamin B and vitamin K. Those are primarily microbially-derived products. We've also seen that implantation of the microbiota of depressed patients can induce some of those depressive symptoms and behaviors in mice. And then one thing that I found really important in my work is that our interventions like Risperidone can also be associated with an altered gut microbiota. So it's not just the antibiotics that we use. Some of these medicines that we use pretty regularly can also have an impact. And I'm gonna shift a little bit and just go into the vitamins and ADHD. We all know ADHD is a chronic neurodevelopmental disorder. It's pretty common. A recent follow-up to the multimodal treatment study of ADHD found that not as many people grow out of it as we once thought. Only about 10% reached sustained recovery for the rest of their life. And it was primarily a waxing and waning of symptoms for individuals. And so when it comes to interventions, we have our first-line interventions with medications and our stimulants, but we know that they come with side effects. And we're always looking for other interventions that we can use, whether it's a non-stimulant medication or different things that we can do with lifestyle. But when it comes to single nutrient interventions, the reason this comes up is in psychiatry, we're kind of taught a single intervention. When we test something, we wanna see what a single thing does and whether or not that has an impact on what we're looking for. But when it comes to nutrition, it's so complex from all the different vitamins and all the different minerals that we have. There are countless chemical processes and pathways, and any one of those things can be thrown off, whether it's from an inborn error metabolism, an isolated deficiency that has a cascading effect, changes to the microbiome, and then just, I think of things like vitamin B and how important it is in the different pathways that we have. Vitamin K for blood clotting, vitamin A and E is antioxidants, vitamin D for calcium homeostasis and immune regulation. So just taking the single intervention approach may not do what we need in nutrition. In 2022, Johnstone evaluated a broad-spectrum multivitamin in ADHD and irritability, and what they did find, there was an improvement in the CGII, 54% of the micronutrient arm versus 18% of the placebo arm. There was no significant difference in the CASI results, but one of the things that they noted was that the multivitamin group actually grew six millimeters more than the placebo group over that eight-week trial. And going further back in 2018, Rucklage used the same multivitamin, same broad-spectrum multivitamin formulation, and this was done in medication-free children. They found overall improvement in function, some improvement in attention, and they also had a subpopulation. They looked at kind of irritability in children, and so they used portions of the Child Mania Rating Scale. They wanted to see how, if there was any impact on irritability, rage, attacks, rapid mood swings, and so when they looked, 62 of the 93 patients met a cutoff of 20, and what they found is that in the multivitamin arm, they had a pretty significant response on improvement in just those specific symptoms, but no overall difference in ADHD. And now, so this was the multivitamin that they used in both studies. It's composed of 13 vitamins, 17 minerals, four amino acids, and a proprietary blend. One thing that surprised me in the studies was that they had a pretty high rate of adherence to the regimen. Some of these kids were taking nine or 12 capsules in a day, which I find hard to believe, but that's what they had, and that was based on pill count and self-report, but it was important to note that they showed the safety of the vitamins, there was a low rate of adverse effects, and that it could be an option if you're just looking at maybe something specific within ADHD. Of note, in the proprietary blend, that has N-acetylcysteine in there, but then also going through the vitamin list, it has things like vitamin D, zinc and magnesium, which have also been studied previously, and have shown some benefit individually. But when it comes to this proprietary blend, I think it's something that we as physicians should be aware of and what it means when our patients go into the store and they get a product and it has this label on there. And so I think of it as just like KFC's original recipe, like it's a trade secret. And what it does for the company is that it allows them to not disclose exact amounts of what is in their blend. They only have to disclose the total amount of the blend and not the individual products. And so you're not sure what you're getting exactly, and you would have to go through independent lab testing to get the specific amounts within that blend. And one other thing that I bring up is, there's Operation Supplement. It's a website that I'll refer to my adult patients in the DOD, because there are supplements out there that active duty personnel can't take. They're prohibited by the Department of Defense. And so it's a good website that I'll send them to just to verify, hey, is what you're buying in the store something that you're allowed to take? But it can be helpful as well in other patient populations. And then I'm gonna pivot to inositol cysteine. All right, so cysteine is one of two sulfur-containing amino acids. We're gonna go back a little bit to BioChem. And what it is, is it's an antioxidant precursor to glutathione. I think in med school, we all are introduced to how we treat acetaminophen overdoses. I think it's something we all remember. There's AcNac, and there's some histogram that we gotta follow. It does more than that. And one of the things, it's been around for 40 years. That's when it got its approval first in the 1960s, but it's been used pretty regularly in acetaminophen overdose for 40 years. It's also used as a mucolytic in cystic fibrosis, and also to prevent contrast-induced nephropathy. So for NAC itself, it does modulate glutamate. There is a cysteine glutamate antiporter, and so that's one of the things that it does for us. It also reduces inflammatory cytokines, increases growth factors. But it protects us from oxidative stresses because it is a substrate for glutathione. And just to talk a little bit about glutathione, it's the primary endogenous antioxidant in our body. It is everywhere in every cell that we have, and it is the most abundant. To put it into perspective, its concentration within most cells is about five millimoles, and that's about the same as potassium and glucose. And it's up there. We need a lot of it. In our central nervous system, the glial cells within the central nervous system have the most amount of glutathione, and that's what supports our neuronal cells in their production of glutathione. And so in kids, one of the things that I've come across, especially nowadays with the increased laxity in the legal system when it comes to marijuana, more and more states out there have legalized it either for recreational use or medical use. In our state of Maryland where we practice, in July it's gonna be legalized for recreational use. And I have a lot more teenagers coming in and saying, well, it's legal, can't be that bad. But when I do have these kids and talk to them about the long-term effects, educate them, it can be difficult for them to break the habit. And so NAC is something that has been studied in the adolescent population, and it's been shown to have a pretty good benefit at decreasing marijuana use. And it also decreased alcohol use in the youth as well. It's also had some benefit in OCD. And these are doses up to 2,700 milligrams a day. And it was associated with significant reduction in the CWOA box total. And it's also shown some benefit in skin excoriation with doses from 1,200 to 3,000 milligrams per day. One other thing that it was looked at was trichotillomania. So the adult results weren't replicated in the children's studies that were done. So there was benefit seen in the adults in a dose of 1,200 to 2,400 milligrams per day. And that was on the mass gen hair pulling scale. The child study, they didn't have any significant difference between the NAC and the placebo. But when I look at the patient populations a little bit more, a much higher percentage of the kids were enrolled in habit reversal therapy, which is considered the first line compared to the adult study. So I think like 8% of the adults were in any type of active therapy. But in the child study, almost 25% were in some type of therapy. And again, it's pretty safe. Like this has very few side effects. And I had one case that I treated that had pretty good response with the NAC and the trichotillomania. When it's on the shelves, it comes in usually 600 milligram capsules or 900 milligram capsules. For the patient that I had who was experiencing trichotillomania, when we dosed it, it was 600 milligrams a day for a week. And then we went up to 600 milligrams twice a day. And then we got 600 and 1,200. And then after three weeks, we got to 1,200 and 1,200. And by a couple months later, that was a pretty good response that she had. And these are my references. And so next up will be Captain Bowie. And he'll talk a little bit more about food deserts and some of the policies that the government has implemented to help with nutrition. So please welcome him. All right, good morning. So I'm Captain Bowie. I'm a staff psychiatrist out at Fort Polk, Louisiana. I would be wearing my uniform at co-presenters, but my flight got delayed. So it's apparently waiting for me back at my hotel now. But I'll be talking about food deserts and the current state of policy and science. So to just start out with, the goal of this part of the presentation is to really understand how food deserts, insecurity, et cetera, can contribute to mental illness in the community and understand how the government's attempting to combat that. In many ways, I think that my previous presenters talked a little bit about how poor nutrition can affect mental health. I'm gonna go a bit further into that and talk about really how this can have a negative impact upon people. And so just to start with, I wanna just go off definitions. So first and foremost, a food desert is defined as an area with limited access to healthy food. Of interesting note, this term was actually first coined in 1995 with the Scottish Nutritional Task Force, actually. So just some history for you. But when it comes to healthy food, that can be a bit of a contentious topic, but in general, we can best define it as typically not ultra-processed food, leafy greens, fresh fruits, things of that nature. But aside from a food desert, there's some other important terminology to be aware of as well. So a food swamp is an area with inadequate access to healthy food, but there's such an overabundance and inundation of other less healthy options that really makes it difficult for the population to get healthy. There's also food mirage as well, in which an area can have access to healthy food, but really can't afford it. I won't touch upon this subject that much, but just something I want you guys to be aware of. And then finally, there's food insecurity, which is just a general term referring to the inability to access sufficient quantity or variety of food because of financial constraints. Looking at the US then, and going through our demographics, we can see there's roughly 23.5 million people living in food deserts in the US. And of those, 2.3 million are those that live in low-income rural areas more than 10 miles from the supermarket. So it's not just a question of people living in the rural areas or things like that. There's a huge variety of people that are in suburban and urban areas that are suffering with food deserts. And kind of going on that, there's about four important aspects to consider when you look at food deserts. Whether or not this population access supermarkets, the racial and ethnic disparities that oftentimes minority populations are typically overrepresented in the people that are affected by food deserts, as well as socioeconomic status, typically those in the lower socioeconomic status have poor access to healthy options. And finally, the differences that exist within chain stores and non-chain stores and what food options products that they can carry. And so while I talked about the population as a whole, food deserts can have pretty negative impacts upon people all throughout their lifespan. And so we're just starting off, initially we can go look at the adolescent populations. So this is a prospective cohort study that was done from 1989 up to 2006, in which they basically followed 14-year-olds and analyzed the behavior through the child behavior checklist. In it, they examined their dietary intake and found that those who had the Western dietary pattern, that is, they take out foods, highly ultra-processed foods as well, things of that nature, typically had higher scores in terms of withdrawal and depression behaviors, as well as delinquent and aggressive behaviors. Conversely, though, when it came to those who had a more healthy diet, characterized by green vegetables, fresh fruit, the burial scores were significantly improved. Moving on to adulthood, we can say that there was a cross-sectional study that was done in which they examined about 5,700 Norwegian adults and examined the quality of their diet and what it was associated with. They found that of those, those that had a Western diet were more likely to be depressed, more likely to be anxious as well. And so here, they defined the unhealthy diet as listed down there, I'm not reading it all, but in essence, processed meats, other unhealthy foods like pizzas and high-sugar sweets, things of that nature, whereas those who had a healthy diet were less likely to be depressed. And healthy diet here, again, defined as vegetables, unprocessed meats, fruits, et cetera. And then finally, looking at the elderly, the elderly are oftentimes at huge risk for poor nutrition. The elderly have oftentimes cognitive functional impairments, poor dentition, decreased appetites, or age-related anorexia. And oftentimes, the elderly will eat simple but poor nutritional diets and thus increase the risk of nutritional deficiency. Thus, there was a four-year prospective court study done from 1999 to 2003, which examined over 1,600 senior citizens in Taiwan. And when they controlled for demographic, you can associate it with lifestyle, though not cognitive status, they did find that fruits and vegetables were protective against depressive symptoms. When they adjusted for cognitive status, it only showed that it was protective against depressive, vegetables were protective against depressive symptoms. But in general, the gist is that a healthy, balanced diet was shown to be overall protective in terms of developing depressive symptoms. And so, I talked a little about food deserts and poor nutrition, how they have an impact upon mental health. But food swamps is another term that's become more and more, I guess, prevalent in the recent years. In essence, the food swamps are areas that are inundated with unhealthy options and highly processed foods competing with healthy options as well. But oftentimes, they can be just as deleterious for the overall health of the population. A cross-sectional study, for example, found that in 2016, that 634 adults in 2016, that 634 adolescent girls studied in Baltimore were found to have significantly more likelihood of eating unhealthy processed foods, such as snacks and desserts, compared to those not living in these food swamps. And so, these food swamps can still just have negative impacts upon people as food deserts can. And in fact, food swamps oftentimes are a strong predictor of obesity compared to food deserts. And increasing and higher obesity can definitely lead to significant physical and mental health issues. And then finally, I want to talk briefly about food insecurities as well. That is to say, the inability to provide enough food for an active, healthy lifestyle. Within the United States, these are the variety of risk factors which can be present of single-parent households, homes with grandchildren. But in essence, whereas food deserts spoke more with the quality of food that you get, food insecurity just refers to overall inability to provide enough food in general. And worldwide, this is important because roughly 100 million people are thought to be food insecure. Furthermore, based upon a global analysis of about 149 nations, there was a noted increased response of worsening food insecurity leading to worsening mental health indexes. It's oftentimes thought that food security can be contributed to common mental health disorders through several different mechanisms, notably by generating uncertainty over the ability to maintain food supplies or acquire sufficient food in the future. Food insecurity can provoke a stress response that may contribute to anxiety and depression. And furthermore, acquiring food in socially unacceptable ways can induce feelings of alienation, powerlessness, shame, and guilt that are associated with depression. In more recent years, there's been some positive news, at least. There's been a thought of general improved access to nutritional food since 2015. The U.S. saw a 15% decline, at least, in the number of people living in limited supermarket access areas, in which it increased from a 5.6% to a 6.8%. However, though, there has been an overall increase in the number of low-income communities as a whole. And that increase is 0.36%. And with the increase of low-income areas, there's a thought that these households might not have access to adequate nutrition. And there's some other brief topics I wanna talk about, as well, that with recent years, there's been a rise of dollar stores in low-income areas. Oftentimes, dollar stores do not provide the same amount of quality of product compared to traditional grocery stores, as well, and also, at times, with limited employment, as well, which is kind of relevant, because it'll stick back to how it kind of makes broad economic impact and impact among the communities. But in essence, dollar stores don't really have the same offerings that grocery stores do, but they oftentimes do arise in more low-socioeconomic areas. Farm markets have been on the rise, as well, over the last few years, a 200% increase compared to 2006, as well as increased use of government support and government food funding for poor families to be used there. That said, though, that despite low-income families using farm markets more often, they're oftentimes still not consuming the amount of fruits and vegetables that is typically recommended. Going back to broader economic impacts, again, food deserts themselves contribute to lost wages and that they don't really have a good infrastructure to really build up a community, build up a good outlet, and really provide employment for the community. Lack of grocery stores in food deserts, as well, can also contribute to significant issues when it comes to the formerly incarcerated, as well. Just an interesting point, but grocery stores oftentimes act as a good way for people who were previously incarcerated to get back and get a job and contribute back to community, but given their lack of presence, doesn't really help people kind of reintegrate back with society. And finally, there is an economic potential for food deserts, as well. Oftentimes, there is a concept called grocery leakage, in which families from low-income areas would oftentimes travel to full-service retailers in middle-income areas to get access to nutritious foods, indicating there is a want in these areas for more healthy options. And so, I spent a lot of time talking about poor nutrition, negative impact on mental health, but how about I take a look at the other side of it, though? And so, there was a 12-week randomized controlled trial that was done in Australia over a three-month period. This was done with people who had severe mild depression, in which six different participants participated. They were divided into two groups, and the intervention was seven nutritional counseling sessions delivered by a clinical dietitian. The control condition was just a social support protocol using the same visit schedule and length. Of these 67, 55 were using some form of therapy, 21 with psychotherapy pharmacotherapy, nine with psychotherapy alone, and 25 pharmacotherapy alone, but they were randomized between both groups. In it, though, they demonstrated that those who did have the dietary intervention had a pretty significant remission of their depressive symptoms, 32.3 percent, compared to the control group, which only had an 8 percent decrease. So, there's definitely evidence that a healthy diet can definitely significantly treat depressive symptoms. And so, we talked a lot about nutrition, food, diets, but what has the government tried to do to help address this problem? Well, kind of going way back in history, governments have always done things to help out with food insecurity and food issues, going back to the dole in Roman times when the Romans would give out grains to its citizenry. But in our timeline here, Starting in 1939, the U.S. started providing a food stamp program to help citizens acquire food. This ended in 1943, but then was restarted back in 1961 and has been going on since then. Since 1973, though, food assistance has been authorized and funded by Congress as part of the Farm Bill. And this legislation is typically revised and reauthorized every five to six years and is administered by the USDA. Relatively recent developments in the development of the Electronic Benefits Transfer, or EBT. And furthermore, to kind of reduce the stigma with receiving benefits, the program itself was renamed in 2008 to the Supplemental Nutritional Assistance Program, or SNAP. It is the largest program in the United States hunger safety net. It provides assistance to roughly 42.1 million people as of a survey in September 2017. Despite that, though, there is still some thought that despite the benefits that it's done, there's still more ways it can go to help further decrease food security and other issues facing lower income Americans. And so when it comes to ways the government has tried to stop or address food deserts, one thought was that, hey, why don't we just open more supermarkets in lower income areas. And so in 2011, there was the Healthy Food Financing Initiative that was part of the federal Farm Bill that year. They provided more than $500 million to help full service supermarkets in these areas. Results were mixed, though. Residents reported an improved perception of the access to healthy food, but there wasn't really much evidence of significant changes to food or vegetable intake nor BMI. So instead, there was another thought about potentially providing bonus dollars or financial incentives to eat healthy foods. This was first done in the 2008 Farm Bill to provide an encouragement of this. And then later on, the United States government started providing more and more, I guess, bonus dollars to help incentivize food intake. This was codified first in 2011, but it followed after a series of local, city, and state financial efforts, the first of which was the 2004 Pennsylvania Fresh Food Financing Initiative. And so the government had provided this program, now needed to study it. And so what they did is they organized the HIP, the Healthy Incentives Pilot Program. In essence, under HIP, SNAP participants received an incentive of $0.30 for every dollar they spent on targeted fruits and vegetables. This study was done from November 2011 to December 2012, and it was done in Hampton County, Massachusetts. This county included urban, rural, and suburban populations with approximately 55,000 households that participated. And of note, Hampton County was the lowest median household income in that state. And so what were the results of this study? Well, pretty good, actually. The study noted that SNAP benefits were spent more upon targeted fruits and vegetables, $12.05 compared to the $10.86 on average. That's an increase of about 11% for people in this program. And then taking it a bit further, the HIP program itself resulted in a 26% more intake of fruits and vegetables among participants compared to non-participants. Two-thirds of HIP households bought more fruits and vegetables, and three-fourths of the households felt they had more access to fruits and vegetables compared to their non-HIP counterparts. And so overall, it was a pretty big success. The costs, though, were a bit high. The program was noted to cost about $4.4 million, and the current thought is that if you take it up to a nationwide scale, the cost would probably be about $90 million to implement across five years, followed by a $800 million to $4.5 billion incentive for retailers and stores that participate in kind of encouraging the spending on these fruits and vegetables. When it comes to more recent things that have been going on, the government then, in 2018, created the Gus Schumacher program, in which basically it incentivized states to create these programs to incentivize fruit and vegetable intake. This program was authorized from 2019 to 2023 and funded about, let's see here, $45 to $56 million. In 2022, for example, they funded about $38.7 million to eight different organizations to implement these incentive projects. Most recently, in 2023, January of this year, the USDA announced the e-HIP project, or the Electronic Healthy Incentives Project, which basically insured states could apply until April of last month. But in essence, they wanted to test this on a wider state-level scale. HIP was done really on just a county-level scale. So I wanted to take it bigger and see if this can lead to that. If we examine this at a state level, we can have continued evidence that this is the way to go when it comes to combating food deserts. All right, and so these are my references, and that is my presentation. Thank you. A couple of things before we start questions. As you can see, I promised you, even though we mentioned we were going to talk about microbiota, we did come around to correlating it with mental health. And I hope, if nothing else from this talk, the take-home message when you go back to making sure your patients are good is, take a couple of minutes at every session and ask them what they eat, and how can the food intake be improved upon. We've touched the very basics. For those who want more details, our previous two talks, the one from 2021 was titled Food for Thought. The one in 2022 was called Food for Mood. This time it's gastroenteropsychiatry, but on the other hand, there is another talk coming up on Tuesday at 3.45, which is titled, in a different way, Eat to Treat. So that will be a follow-up. If you can, if you're still here, please come and visit us. I thank you all for attending today and for giving us the opportunity to present our thoughts. Also like to thank the APA Committee for having approved of our proposal. And now I open this to the audience. If you have any questions, we'll try and answer them, or we can get back to you if we can't. Thank you. Thank you for the good and comprehensive presentation, all of you. Any particular vitamin or supplement do you recommend for ADHD and autism spectrum disorder and OCD? Different diagnoses, but a lot of patients with those diagnoses. So nothing, no specific brand or no specific product, but the things that I often recommend are omega-3 fatty acids. So those have shown in several trials to have benefit in ADHD. No multivitamin, no specific multivitamin. I just think that in general they help kids fill in a lot of deficiencies that they have in their diet. But then other ones, vitamin D is something that I often check as well, because it is something that is pretty prevalent. You'd be surprised at the rates of vitamin D deficiency that we have in the United States. And that has a whole cascade effect on our brain and our central nervous system. But those are the three primary ones. Robotics as well, but like I said, we're not at a point where we can say a specific strain or a specific product has more benefit than any other ones. So as far as if you have to pick for ADHD, you would give multivitamins versus B-complex. Of course, omega-3 fish oil, there is a lot of studies for that. But you would pick multivitamins versus B-complex. Yeah, I may land on just a multivitamin at first. Make sure that it has a good spectrum of different minerals and vitamins that it's covering, but no specific one vitamin. Okay, thank you. So I can add one more thing to it. Specifically not for OCD or ADHD, but there are two food items that have been investigated a lot, and they have found to be of benefit. One for anxiety, and that's blueberries. And guess which type of chocolate is advised for those who have depression along with anxiety? Is it the milk, the white, or the dark? Dark. Dark. There you go. You already know the answer. Thank you. My name's Katie. I'm a psychiatrist in San Diego, and I practice integrated care. But I want to go back to Dr. Nguyen's comment about the difference between the French diet and attitudes around food and the U.S. American diet. I was an exchange student in France, and I speak French. And navigating that cultural difference was actually one of the biggest things that I had to learn and adjust to. And I worry that, although I loved your talk, I loved all the evidence, the scientist in me loves to see the biological underpinning, I worry that this reductive approach to nutrition that we have adopted in the United States, where we talk about specific nutrients and even micronutrients, really gets us away from focusing on food and improving our nutrition. And when you think of the deficiencies in vitamin D, and the deficiencies in all the vitamins, and the gut microbiome, and even the tight junctions, all of that would be improved by eating real food, more fruits and vegetables, less processed foods. So can you speak to your, and I'm actually giving a talk on Wednesday, and I'm bringing our registered dietician with us, and we're talking about how we can treat, and how we've treated mood with food and our approach to that. But can you speak to how you've approached that, particularly in the adolescent and pediatric population, when they might not even have very much control over what they eat, how you can affect a family system to improve their nutrition with and without an emphasis on micronutrients and supplements? Because I just feel like we're not going to really improve the health of our population with supplements. Thank you. So yes, to all of the above. To answer your more recent question about how I approach this in the clinic, and I think you already kind of hit it already on the nose by calling it a system. You know, going into child and adolescent, yes, you know, it is one patient before I got into there, you know, it's just the person in my room. But when I got into the child and adolescent care, I began to appreciate that everything is connected in a very certain system more than anything else. So to speak to the idea of reductionism that you brought up, yes, I do think it is a little bit hubris for us to say that there's one drug for this one very specific scenario and context. And to go back to the lycopene and olive oil kind of example that I give out, it's all in a system. And the more and more we try and isolate to that one item, you know, I would even argue to say that I don't know if there are any validation studies about very particular vitamins being absorbed in certain context as well. So when I approach this in clinic more than anything else, I like to at least tell the families and the kids, you know, look on the label more than anything else. If there's quite a few things on there that you cannot pronounce or, you know, your great, great, great grandmother cannot identify, generally we don't know what it does more than anything else. And then, you know, have some mindfulness by having either too much of it or even just having it around in the household. That is usually like my first go-to. And then after that, you know, a lot of it really is kind of coaching the parents about that. And then with my marines and everything, I just tell them don't do it. Thank you very much. One more thing that I would like to add is we're not in any way saying that food can replace medications. This is something that you should use for every patient you provide is while you're treating them with medications and therapies and telling them to be more active and meditate and all the others. Think of food also as one more adjunct therapy that you should be considering. And if there is change to be made for the better, please advise them so. Thank you very much for an excellent presentation on a very important topic. I hope we'll have more in future meetings. I wanted to just bring the attention and see if the panel has any comment about the correlation between trauma, especially early childhood trauma, but also with adults and gastrointestinal and mental health issues, the correlation. So I have seen both in studies and research, and I wonder if you have that experience, but there are correlations that children that were exposed to childhood stress or childhood trauma have much more prevalence of leaky gut and other serious gut issues. It happens also in adults that have serious trauma that they actually, their gastrointestinal system gets messed up and they can't actually eat normal food for a while at least. And it also increases the rate of food sensitivities where children had childhood trauma or adults that had severe chronic trauma or something like that. I was wondering if you have any comments about that. I do. It reminds me of the book that I read, The Boy Who Was Treated As A Dog. Do you guys know the book at all? There's a particular case in there that talks about, you know, as an adopted individual who for some reason would not be meeting their 50 percentile weight and height curve. And it wasn't until a particular caretaker didn't treat them like an eight year old and kind of coddled them for the entire time that they began to grow. So when you're kind of talking about this idea of trauma affecting the microbiome, my answer is yes. Because more than anything else, their nervous system has begun to wire to become a little bit more overreactive. At least how I view it when it comes to the idea of hypervigilance and the sympathetic system as well as the autonomic system. So with that being said, something as simple as like an increase in the IL-6 in their colonic system can probably lead to a leaky gut more than anything else. I don't have a specific study more than that, but I do believe that notion more than anything else. And I think we can all appreciate how complex the downstream effects of trauma can be. So I'm going to foot stomp this again. Don't take it out of context of the system, especially the biological one. Because, you know, I don't think all traumas are the same and I don't think all reactions are the same as well. But I wouldn't be surprised if there is an inflammatory response later on that leads to a dysbiosis. To add to that, the whole system, the brain-gut microbiome is bidirectional. It goes both ways. So the brain influences the microbiota as much as the other way around. I think you raised your hand. Oh, I'm too short. Thank you for this great presentation. I really appreciated it. As a kid, I had a history of like anorexia and that really inspired me towards psychiatry. And in my recovery process, I remember when I was first recovering, I ate a lot of like super processed foods because I could control like how many calories were in the foods. And that made me feel worse. And during medical school, I got a lot better. And I guess my question is, is there anything being done on a systemic level to address what types of foods are given to patients like in the psych wards? Because in my medical school, I saw that the kids were eating like potatoes all the time and Oreos in the adult psych wards. So at least in my research, I've only seen things from the government standpoint. When it comes to each individual hospital's practices, I think it's really just dependent upon what their dietician would recommend and do. So at least from what I've seen, I haven't seen systemic ways to address diet in terms of the ward or anything like that. So I don't know is the best is what I can say. I guess is there anything that we can do like as a group to address this? Yes. Join leadership positions, learn how to advocate, and more than anything else, know how to manage your leaders. Because at the end of the day, yes, that Oreo that's going into the nine-year-old ADHD child in the inpatient ward, the Oreo is allowed. Why is it allowed? Probably because of some policy or lack thereof. So in order for that to trickle down, it has to start from the top somewhere. And you have to really break into that ice. And I'm a big proponent of policy as well as advocacy. And I really think that's a lot of our work sometimes when it comes to what we owe to our patients, especially in say the inpatient setting. I mean, that's definitely not going to help the ADHD. And I've fought that battle before, but there's a right way to do it. There's one other important issue to think about, and that this is still a new science. The whole concept of gut microbiome and how it affects mental health and vice versa. Not much research is being done about it because obviously there's no money involved. Nobody's going to do a food lobby and go to the Congress and say, this food is good for you. You have to do something about it. So unfortunately, the research is not a whole lot. Those who are dedicated people continue to do research. And your question about adolescence is a great question. Hopefully we'll be able to address it at the next New York session in much more detail. Every year we get new details. I think there's only one minute left. So in traveling with the military and outside the military, I've made a point of eating yogurt in any location I go to. And generally it keeps my gut pretty healthy, I think. Also, I'm going to add to that the fermented foods. Thank you. I will do that from here on out. But I did have a question. You mentioned the Tibetan monks. You mentioned the French diet. Are there any places that one could travel to that probably has the most pro-mental health microbiota that we could enjoy with through our travels? Farmer's market. So as far as the world is concerned, Mediterranean diet is considered the ideal diet to have. Japanese diet is also not far behind in terms of how the mental health can be affected by diets. But of course, the nearest place is the farmer's market. Seasonal foods, and going with that. And I say that because not only are you helping your community, as well as the policy, as well as the advocacy in that area, but the carrot that you're eating there is from the soil that is there, as opposed to a transported carrot from, I don't know, Iowa? Do they grow carrots there? So it shouldn't be high in the farmer's market. There's one thing you should all know about yogurt. Not all yogurts are made equal. And if you just pick up any yogurt you feel like from the supermarket, you might not be getting the best. Ideally, the yogurt should not be sweetened or flavored. That reduces the count of bacteria. So please be aware of that. We have seconds left. A question about antibiotics. When we cannot avoid giving or taking them, what would be the strategies to reduce the damage? And what are the time frames to help those strategies? Yeah. I think one thing that we do is we'll recommend probiotics when patients start to take an antibiotic. And it will help a little bit with just the diarrhea associated with it, but can kind of help provide a little bit more support during this episode of dysbiosis. And no in particular probiotic to go with it, but also recommending increased probiotic foods like yogurts, kimchi, kombucha. Those are things that could also be helpful. And I was thinking about this as well, but I really wish that there was a screener or a scale or a way to assess how much someone is susceptible to dysbiosis before prescribing said antibiotic. Because if they do have a diverse, resilient, as well as a non-fragile microbiome, I think they can potentially tolerate that a little bit more and spring back. Yeah. So what are my thoughts? Thank you everybody for joining us today. See you guys around.

gastroenterosarchiatry

gut microbiome

mental health

diet

probiotics

prebiotics

multivitamins

ADHD

anxiety

nutraceuticals

food deserts

omega-3 fatty acids

nutritional gaps