CCPR: Thanks for joining us today, Dr. Ramsey. What is our place as mental health professionals in addressing nutrition? 
Dr. Ramsey: Mental health professionals have unique roles in helping patients address nutrition. We have more time with patients than other professionals. Our patients see us a lot. And we help people change, including dietary habits. For folks in their teens and 20s, you are a unique adult in their life. You work collaboratively with them. Your interest is in making sure they feel good, whatever that means to them, within reason. We are not just giving them rules—like sleep hygiene rules and diet rules—but letting them explore.

CCPR: What research is there on nutrition and mental health?
Dr. Ramsey: Research shows that adults have about a 20% reduction in the risk of depressive symptoms with a Mediterranean diet—lentils, wild salmon, and collard greens—as opposed to ultra-processed foods. This is also true for a Japanese or Norwegian diet. In the 2017 SMILES trial, subjects who received 7 nutritional counseling sessions had a 32.3% rate of remission from depression. Some received antidepressants or psychotherapy. Later analysis found that ultra-processed foods led to weight gain, diabetes, dyslipidemia, and visceral fat accumulation. All of these increase inflammation, dysbiosis, and problems in the microbiome. 

CCPR: Tell us more about the microbiome.
Dr. Ramsey: The microbiome is a collection of diverse symbiotic organisms, mostly gut bacteria, that produces important products such as short-chain fatty acids and is involved in immune regulation and digestion. For our microbiome to function well, we need to feed it fiber and fermented foods such as kombuchas, kefir, miso, and sauerkraut (Leeuwendaal NK et al, Nutrients 2022;14(7):1527). If we do that, the microbiome can provide us with a better-regulated immune system, better gut health, and potentially also better mental health. 

CCPR: Are there data specifically related to nutrition and mental health in youth?
Dr. Ramsey: A trial in Australia of college freshmen screened students with poor eating habits for depressive symptoms (Shi Y et al, Nutrients 2022;14(21):4522). Researchers gave students a box containing olive oil, nuts, nut butter, cinnamon, and turmeric. They also had the participants watch a 13-minute video on the impact of diet on depression and participate in two 5-minute phone calls—the total intervention was 23 minutes. Over three weeks, mood rating scales improved versus a comparison group, although that may be partly due to the extra attention they received. 

CCPR: What kinds of ideas do kids have about food and nutrition?
Dr. Ramsey: It’s a mixed bag. Adolescents and young adults get so much misinformation and bad messaging around food. There is so much focus on muscle building and body shape that the fundamentals of self-care are lost. I have 18-year-old men saying to me, “Doc, you gotta check my T because I ate tofu!” They think that they are tired, anxious, and losing hair due to low testosterone. We need to help them think about how their nutrition is impacting their energy and make reasonable connections to their mental health. For example, we can help kids and teens eat more whole, real foods and less processed foods. We can ask about food security and what they like to eat. On the other hand, some teens are informed and curious about food and nutrition, which is great for alliance building. The bottom line is that youths today are thinking about food and are targeted by a lot of food marketing.

CCPR: When should we get a detailed assessment of food and nutrition? 
Dr. Ramsey: Include nutrition and lifestyle questions in your initial assessment, and think of food choices as an ongoing intervention. Whether your patient is struggling with ADHD, depression, or substance use disorder, be curious about their relationship with food: “What is this patient’s dietary pattern and where do they get their food?”

CCPR: How should we ask kids and parents about their diet?
Dr. Ramsey: Do it in a neutral way. Ask patients as well as parents questions about, for example, their favorite food. If it’s pizza, ask what they like on their pizza. What don’t they like—what textures or tastes? Don’t fret about sugar. When was the last time they ate pesto? How much tinned fish do they have in their house? What’s the family’s favorite fermented food? Is there a kombucha flavor that they all like? Listen for opportunities to make positive changes.

CCPR: Do you have an example of an opportunity to change eating habits? 
Dr. Ramsey: As a personal example, I made breakfast for my daughter, and she had eggs. I also made graham crackers with Nutella. My wife said, “She should take them to school, so she doesn’t eat them before the eggs.” That was great. When you take a complete history with families, it gives them space to step back and think about similar ways to make gradual changes. Knowing what to do and then doing it are separate hurdles for families. As good clinicians, we want to help them with both. 

CCPR: Do you ask about contaminants in food such as heavy metals?
Dr. Ramsey: I don’t worry much about heavy metal contamination. While there are potential problems that may arise, research on the actual effects is lacking at this time (Choudhury S et al, Bull World Health Organ 2022;100(3):180–180A). Food and supplement marketers are undermining common sense and confidence. Reports of problems with arsenic in rice seem ridiculous. Kale has been derided as being full of oxalates, but kale is at the top of the list of low-oxalate greens. The benefits of omega-3 fats are so clear, and we should shift meals from meat to seafood. We can reduce mercury and contaminants by eating fish that are low on the food chain—anchovies, sardines, and wild salmon—two to five times a week. There are concerns about dark chocolate and contaminants. These are not the root cause of the mental health epidemic. 

CCPR: What about microplastics? 
Dr. Ramsey: Microplastics are a potential concern. The idea of endocrine disruptors such as phthalates from plastics impacting our health seems to be gaining evidence (Blackburn K and Green D, Ambio 2022;51:518–530; Winiarska E et al, Environ Res 2024;251(Pt 2):118535). I tell families to try and limit exposure whenever possible by not eating food that is sold in plastic or stored in plastic, microwaving food in plastic, or drinking from plastic bottles. I also tell them to use only the paper tea bags, not the ones in plastic mesh bags. 

“When we talk about medications, a lot of times patients are concerned and hesitant. Food is similar, and we have an opportunity to work with our patients in an integrated fashion where nutrition is part of better psychopharmacologic care.”

Drew Ramsey, MD 

CCPR: Do you have any thoughts on using diets in place of medication? 
Dr. Ramsey: It’s not an either/or choice. Good outcomes in psychiatry are more likely when people make a healthy lifestyle choice by eating a more traditional diet—that is, a balanced diet that is made up of actual foods rather than processed products. Often, diet is explored as an alternative to avoid medications. Focus on reducing stigma and on outcomes. 

CCPR: What are your thoughts about our role in the nutrition of kids and teens who are taking psychotropic medications? 
Dr. Ramsey: It’s important to follow up and monitor weight longitudinally, even for kids on selective serotonin reuptake inhibitors, and especially for those on second-generation antipsychotics. We are the ones giving that medicine, so it’s on us to help manage the side effects. I also find it helps build the therapeutic alliance. When we talk about medications, no matter what way we slice it, a lot of times patients are concerned and hesitant. I think conversations about food are similar, and we have an opportunity to work with our patients in an integrated fashion where better nutrition is part of better psychopharmacologic care. 

CCPR: Where would you place the Mediterranean diet, or a diet change, on a depression algorithm for kids and teens?
Dr. Ramsey: I would put it early, but also make sure not to overwhelm people. I’m from the Midwest, so when you mention “Mediterranean diet,” that means pasta or pizza. We need to turn that into snacking on olives and almonds. When you’re feeling hungry in the afternoon, get out a little Manchego cheese and some pickles. Think about things like anchovies and sardines in your diet. That sounds expensive, but good foods like fresh vegetables, beans, nuts, and seafood can be very affordable. Remember that this is a lifestyle approach. Beyond the act of shifting one’s diet, people can gain mental health benefits from eating together, cooking, and valuing healthy cultural food traditions. 

CCPR: What about gluten-free diets? 
Dr. Ramsey: Both true and overhyped. Half of people who have celiac disease don’t know it. If you don’t know you have celiac disease and you stop eating gluten and bread products, you are going to have a health revolution: no diarrhea, bloating, or itchy skin. But gluten allergy is not common. Elimination diets might be helpful, but those are more useful in identifying common food allergens such as eggs, seafood, or nuts. 

CCPR: What do kids and teens need in their diet to support better mental health? 
Dr. Ramsey: More real food! Help kids and parents get closer to a traditional style diet. I have a mantra: “seafood, greens, nuts and beans, and a little dark chocolate.” Start there. You’re happy because it’s delicious. Your cardiologist is happy you’re eating oily fish and plants. Your psychiatrist is happy you’re eating a more traditional-style diet. 

CCPR: What would be a next step?
Dr. Ramsey: After taking out most ultra-processed foods, try more advanced moves like increasing fermented foods, eating more fish, and sampling more diverse plants.

CCPR: How might we get kids and teens to accept the changes in their diets? 
Dr. Ramsey: Make it fun and delicious. Empower kids to explore and make food. Avoid processed foods, but don’t be so restrictive that kids can’t have a childhood. When kids are on restrictive diets and not allowed to participate in things like eating birthday cake, that also has consequences. In my book, Eat to Beat Depression and Anxiety, I write about our evolution as eaters. Patients can learn about themselves, about food, and about recipes. I work with young men who learn to cook and care for themselves, and it’s a wonderful thing to behold. Fermented food is fun to explore—you can make sauerkraut or sourdough bread together. 

CCPR: What other tips can we offer parents working with their kids to improve diet?
Dr. Ramsey: As parents, you don’t want to be fearmongers, but you need to pay attention to the dietary pattern. Focus on high-quality snacks like nuts, yogurt, fruit, and crudité. Reduce fried food—replace French fries with oven-roasted vegetables. It’s important to engage the whole family in dietary changes. If parents are having trouble creating and implementing ­better meal plans, consider referring them to a registered dietician. 

CCPR: How do we help kids eat more plants?
Dr. Ramsey: Kids need help finding plants they enjoy eating. The point is not vegan vs carnivore; it’s that more people need more plants. Kale is great, but if you don’t like it, you can eat arugula or any of the other leafy greens. For kids’ mental health, think about folate (vitamin B9) in leafy greens and especially lentils. Use leafy green vegetables as pesto or in a smoothie. They are nutrient dense and correlate with decreased depressive symptoms (Radavelli-Bagatini S et al, Eur J Nutr 2021;60:3743–3755). Vitamin B12 is in meat, but the top source is clams, and it can help a lot for some depressed youths. I treated a depressed 18-year-old by sharing electronic notes back and forth, helping him to make pasta alle vongole (pasta with clams). It was a fun way to engage with him.

CCPR: Kids eat everywhere, including at school. Is there anything we can do about school food? 
Dr. Ramsey: Kids and adolescents do eat a lot of cafeteria food. If you engage kids in making bag lunches that they love, that can go a long way toward shifting their dietary choices. I am a fan of chef Dan Giusti and his organization Brigaid (www.chefsbrigaid.com), which trains school chefs to start cooking from scratch again. They are getting kids to eat and engage with healthier food, and that can make a huge difference in health and mental health over time. 

CCPR: So to sum it up, where do you place nutrition in the broader context of mental health care for children and teens? 
Dr. Ramsey: We have evolving evidence around food and mental health, and I’m excited about using nutrition to prevent and manage depression and other mental health problems. It’s a low-risk approach and a good way for us all to take better care of ourselves.

CCPR: Thank you for your time, Dr. Ramsey.