Contributing factors are substances, contexts or conditions that have roles in the causation or promotion of anxiety.

Diet is commonly considered the most important mediator of health and disease. Healthy diets can help prevent anxiety while poor diets can promote and sustain anxiety. Research shows that (Davison & Kaplan, 2012):

• People with anxiety and depression tend to have poorer diet quality than those who do not experience these conditions
• More chronic or severe the anxiety symptoms correlated with worse quality of diet

Mediterranean diet and anxiety

• The mediterranean diet is considered a good model for a healthy diet. It includes foods that are beneficial, and also reduces or eliminates foods that promote mental health issues.
• General components of the mediterranean diet include:
  • plenty of vegetables and fruit
  • healthy fats including olive oil
  • regular consumption of seafood
  • poultry, beans, and small amounts of red meat
  • small amounts of dairy as yogurt and cheeses.
  • whole grains instead of refined grains

Following a Mediterranean-type diet decreases risk of anxiety and depression. (Sadeghi et al., 2019)

Mediterranean diet for heart health

Mayo Clinic
https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet/art-20047801

• Refined sugars are sources of carbohydrates, but lack the nutrients required for their metabolism (breakdown in the body). As a result, the body’s reserves of nutrients are used instead. With chronic sugar consumption, the body becomes depleted in nutrients – especially those that have roles in preventing anxiety.
• Sugar may also increase blood lactate levels. Increased blood lactate increases risk of anxiety.
• Symptoms of hypoglycemia can be confused with, or trigger anxiety. (See hypoglycemia section)

Gluten is a general name for proteins found in wheat and related grains. Although many people are not affected by gluten, for others it can cause problems, including anxiety, for a variety of reasons.

• With anxiety patients, the foods most often involved with symptoms contain gluten (Scott, 2011)
• Gluten can damage the digestive tract, resulting in decreased nutrient absorption, and increased inflammation
• The gliadin component of gluten can be improperly converted into gluteomorphins – which are addictive. Withdrawal symptoms include anxiety and depression (Scott, 2011)
• Gluten sensitivity can decrease serotonin (Pynnönen, 2005). Low serotonin is a risk factor for anxiety.
• Removing gluten from the diet can help resolve anxiety – especially in people who do not benefit from anti-anxiety medications (Potocki, & Hozyasz, 2002)

Sources of Gluten

• grains: wheat, rye, barley, triticale
• grain byproducts: brewer’s yeast, malt, starch
• pastas, noodles
• baked goods: bread, cakes, cookies, crackers
• sauces and gravy (starch)
• beer

Artificial sweeteners/aspartame and anxiety

Artificial sweeteners are widely used in processed foods. They are synthetic molecules which have variety of affects on metabolism, including brain function. Artificial sweeteners include:

• acesulfame K,
• aspartame
• neotame
• saccharin
• sucralose

Anxiety is a reported side effect of aspartame consumption (Roberts 2013). Aspartame has been shown to worsen nervousness and depression, and cause headaches, insomnia, and dizziness (Bradstock et al., 1986; Humphries, Pretorius, & Naudé, 2008)

Monosodium glutamate, the sodium salt of glutamic acid (glutamate), is one of the most commonly used food additives in commercially prepared foods. It is a flavour enhancer that has the taste sensation of “savoury”.

Common food sources of MSG include (Kubala, 2020):

• fast foods and snack foods
• seasoning blends and condiments
• frozen meals
• soups and instant noodle products
• processed meats

Glutamate is an amino acid that excites the brain and is involved in the pathophysiology of severe and chronic psychiatric conditions, including anxiety and depression disorders. (Kraal et al.,  2020)

Glutamate has been shown to promote elevated psychological and physiological arousal processes that may relate to anxiety (American Psychiatric Association, 2013)

Animal and human studies have shown that even minimal amounts of MSG have toxic effects on the body. Some of the toxic effects of MSG may be lessened by vitamins A, C, D, and E (Niaz, Zaplatic, & Spoor, 2018)

Alcohol has been shown to increase feelings of anxiety (Montiero, Schuckit, & Irwin, 1990) This may be due to the fact that alcohol depletes several essential nutrients required for preventing anxiety, such as vitamins B1, B6 and folate, vitamin C, magnesium, zinc, and fatty acids (Pizzorno & Murray, 2000).

Alcohol has also been shown to promote hypoglycemia and decrease serotonin (see hypoglycemia and anxiety section)

People with anxiety may react to ingredients in alcohol including wheat, rye, barley, corn, and added sulfites.

Alcohol inhibits gluconeogenesis from lactate.This inhibition increases the lactate to pyruvate ratio. People who are sensitive to lactate can then be more prone to anxiety attacks.

• Caffeine can cause anxiety in normal individuals, but can be especially provoking in pre-existing anxiety disorders (Broderick & Benjamin, 2004)
• A single cup of coffee, or even a few sips of a caffeinated beverage can be problematic in patients with anxiety disorders (Boulenger et al., 1984; Clemenz & Dailey, 1988)
• Chronic or heavy use of caffeine can increase anxiety (Clemenz & Dailey, 1988)
• Long-term caffeine consumption is linked to anxiety and depression (Bruce & Lader, 1989)
• People with panic disorders and/or social anxiety are more sensitive to the anxiety effects of caffeine (Lara, 2010)

Effects of caffeine on anxiety

• Effects of excessive caffeine consumption can be indistinguishable from anxiety symptoms. These effects include nervousness, irritability, palpitations, insomnia. Caffeine withdrawal can also mimic anxiety (Greden, 1974)
• Other known effects of caffeine associated with anxiety include: increased heart rate, body temperature, blood flow, blood sugar levels, and the promotion of insomnia

Roles of caffeine in anxiety

• Caffeine depletes B vitamins, vitamin C, potassium, magnesium, calcium, zinc (Scott, 2011)
• Caffeine increases lactate in blood. This results in people who are sensitive to lactate being more prone to anxiety attack (Pizzorno & Murray, 2000)
• Caffeine increases adrenal production of epinephrine and norepinephrine, which over time, can weaken the adrenal glands (Levi, 1967)
• Excess caffeine makes the way the body responds to hypoglycemia worse (See Hypoglycemia and Anxiety section)

People with anxiety may metabolize caffeine slower than average person, resulting in higher peak concentration, or increased sensitivity to caffeine (Gaby, 2011)

• Nicotine is a stimulant compound found in tobacco and it has been shown to increase heart rate and blood pressure.
• Smoking increases the risk of panic attacks and panic disorder (Goodwin, Lewinsohn, & Seeley, 2005)
• Although smoking can temporarily relieve immediate anxiety symptoms, chronic smoking can increase chronic nervousness and agitation.

• Heavy metals like mercury, lead, and cadmium are prevalent in the environment we live in.  Accumulation of heavy metals in the body and brain affect mental health.
• The brain is especially susceptible to accumulation and storage of fat-soluble toxic metals due to its high fatty-acid composition (Orisakwe, 2014).
• Mercury accumulation from environmental exposures, consuming mercury-containing fish and having dental fillings have been shown to promote anxiety and agitation (O’Carroll, Masterton, Dougall, Ebmeier, & Goodwin, 1995: Kidd, 2000)
• Lead accumulation may be implicated in anxiety and panic attacks (Bouchard et al., 2009)
• Attention, psychomotor activity, and memory are negatively affected by cadmium, and exposure during prenatal and neonatal periods has been shown to cause anxiety, mood disorders, and schizophrenia later in life. (Orisakwe, 2014).
• Excess copper increases the conversion of dopamine to norepinephrine and epinephrine in the body. This conversion can promote feelings of anxiety, panic, and agitation (Tsafrir, 2017).

Many patients will improve with a basic protocol of a healthy diet, supplementation of essential nutrients, exercise, and rest. Sweating from exercise or saunas can also help remove toxic metals (Sears, 2018).

It is important to work with a practitioner that is trained in detoxification when addressing excessive or chronic heavy metal exposure or accumulation.

• Some medications promote anxiety by causing symptoms that include restlessness, nervousness, insomnia. Some implicated medications include decongestants, steroids, and respiratory medications.
• Antidepressant medications can promote anxiety, depression, addiction, suicidal tendencies, tremors or involuntary muscle spasms, and senility (Murphy, 2009).
• Benzodiazepines are associated with numerous unwanted side effects, including poor sleep, seizures, mania, depression, suicide, ringing in the ears, amnesia, dizziness, anxiety, disorientation, low blood pressure, nausea, fluid retention, tremors, sexual dysfunction (decreased desire and performance), weakness, somnolence (prolonged drowsiness or a trancelike condition that may continue for a number of days), and headaches (Murphy, 2009).

Many types of medications deplete essential nutrients that have roles in preventing anxiety. Research has shown that:

• Oral contraceptives, antidepressants, and decongestants deplete vitamin B6 (Pelton, LaValle, & Hawkins, 2001)
• Corticosteroids, ACE inhibitors and oral contraceptives deplete zinc.  (Scott, 2011)
• Lead may promote anxiety, panic attacks, and depression (Bouchard et al., 2009)

Further information

An in-depth examination of common medications and nutrient depletions. (Mohn et al. 2018)
https://doi.org/10.3390/pharmaceutics10010036

Nutrient DEFICIENCY:

• When the minimum amounts of nutrients needed for normal body function are not met by diet
• A nutrient deficiency results in depletion of nutrients in body tissues, and changes to mental and physical functioning from diet, medications.

Nutrient DEPENDENCY:

• The metabolic need for a nutrient exceeds what can be supplied by diet and results in impaired biochemical processes and functions.
• A nutrient dependency results from long-term environmental and genetic stressors.

• Food sensitivities can cause imbalances in key brain chemicals and can cause anxiety, phobias, depression, irritability, mood swings (Pfeiffer 1987: Rippere & Phil, 1984)
• “Adults and children suffering from food allergy show impaired quality of life and a higher level of stress and anxiety” (Teufel et al., 2007).

Food allergies and sensitivities that affect the brain can be referred to as “cerbral allergies”. Cerebral allergies encompass more than antibody-antigen reactions.

Cerebral allergies are mediated by:

1. direct biochemial effects of substances found in food or drink, for example caffeine, alcohol, and sugar
2. hidden or delayed allergic reactions to food or drink, for example wheat, milk, corn, and egg

Foods commonly associated with allergies (Prousky, 2015):

• dairy products
• wheat, rye, barley
• eggs
• pork, beef, seafood
• soy
• corn, tomato
• citrus fruits
• nuts, peanuts
• chocolate
• coffee, tea
• sugar
• yeast

• Symptoms of hypoglycemia can be confused with, or trigger anxiety.
• Hypoglycemia a common contributing factor or main cause for anxiety (Rippere & Phil, 1984): Salzer, 1966).
• Fatigue, irritability (Eaton & Konner, 1985) and nervousness, sudden mood changes, rapid heartbeat (Nall, 2012), are common physiological symptoms of hypoglycemia

How hypoglycemia promotes anxiety

• Consuming a high-carbohydrate meal or drink causes a rapid rise in blood glucose. The high glucose causes the pancreas to release an abnormally high amount of insulin into the blood, which cause an abrupt drop in blood glucose.
• The excessive drop in blood sugar triggers the release of the hormones epinephrine and norepinephrine, which in turn, trigger the fight or flight response.
• The fight or flight response shows up as hunger, irritability, sweating, palpitations, and anxiety.

Identifying hypoglycemia:

• People with hypoglycemia tend to crave sweets.
• Consuming sugar or refined starches temporarily reduces the anxiety symptoms.
• Symptoms worsen in the late morning or late afternoon.
• Mental and anxiety symptoms occur after fasting, late at night, or first thing in the morning (Eaton & Konner, 1985).
• Typical medical tests to assess blood-sugar metabolim are fasting glucose, HbA1c, but can also include insulin, cortisol, ketone bodies, lactic acid, free fatty acids, and thyroid hormone (Mandal, 2019).

• Pyrroles are a by-product of hemoglobin production and normally excreted in the urine.
• Pyroluria is a condition of overproduction of pyrroles (McGinnis 2008a, 2008b). Excess pyrroles bind vitamin B6 (pyridoxine) and zinc, removing them from the bloodstream.

• anxiety and depression
• mood swings
• poor stress control
• severe inner tension
• episodic anger
• nervousness
• poor short-term memory

Supplementation support for pyroluria (Greenblatt, 2018)

• 200-800 mg of vitamin B6 in the pyridoxal-5-phosphate form
• 25–100 mg of zinc

Dr. Jonathan Prousky (2006) stated, “Although I could test for this compound [HPL], I choose not to, since these nutrients are inexpensive and have minimal side effects. The daily dosages I routinely start with are 250 mg of pyridoxine and 50 mg of zinc”.