Nutrition in women with schizophrenia
Women with schizophrenia have physical and mental health needs that differ from those of men, and these needs vary according to the stage of the life cycle (Natividad et al., 2023). One of the most significant problems globally is that women have poor access to medical services in some parts of the world (Mahase, 2019), which means that some of them experience medical comorbidities and a severity of clinical symptoms that are not as common in men.
After menopause , women with schizophrenia have specific health needs compared to pre-menopausal women. This is because the decline in estrogen levels at this stage of life, along with socioeconomic factors and lifestyle, undoubtedly impacts their health differently than it did during their reproductive years (Seeman, 2023a). Following menopause, women experience increased rates of substance use, obstructive sleep apnea (OSA), hypercholesterolemia, diabetes, obesity, and osteoporosis.
In general, schizophrenia has been associated with an increased risk of premature death, making prevention and early intervention strategies highly recommended (Yung et al., 2021). Respiratory and cardiovascular diseases, as well as cancer, have been identified as the leading causes of morbidity and mortality in schizophrenia. Recent studies highlight the need to develop strategies to improve the physical health of patients receiving care , with particular emphasis on gender differences (Yung et al., 2021; Natividad et al., 2023).
The necessary gender perspective on psychosis
On the other hand, it is worth noting that social risk factors negatively affect both men and women with schizophrenia; however, these factors have a more severe impact on women and contribute more frequently to increased stigmatization (Jester et al., 2023). Some of these factors include discrimination and social exclusion, living in an urban environment, low socioeconomic status, housing difficulties, and traumatic experiences in childhood, adolescence, and adulthood, among others.
Strategies must be designed to improve the physical health of women with schizophrenia, who have needs that differ from those of men and that vary according to the phase of the life cycle.
Given the physical and mental health needs and psychosocial risk factors experienced by these women, within the community mental health service of the adult mental health department at Hospital Universitari Mútua Terrassa , we launched a pilot project in January 2023 called the Functional Unit for Women with Schizophrenia-Mútua Terrassa ( Unitat Funcional de Dones amb Esquizofrènia-Mútua Terrassa, UFDE ) (González-Rodríguez et al., 2023). The main objective of this pioneering project in care from a gender perspective is to improve the physical and mental health of women with schizophrenia and to identify the social determinants that impact their health in order to intervene early. The working model of this Unit is based on Observatories (for morbidity and mortality, substance use, medication safety, etc.) that, through collaborative work, identify unmet needs and design specific interventions for the women who require them.
The impact of diet on schizophrenia
A cross-cutting aspect of particular interest within the Unit is the consideration of nutrition , diet, and lifestyle in women with schizophrenia , which, as previously mentioned, directly impacts their overall health. In recent years, knowledge of the relationship between nutrition, symptom expression, schizophrenia progression, and morbidity and mortality in schizophrenia has grown considerably in recent years (Onaolapo and Onaolapo, 2021).
Social risk factors have a particularly negative impact on women with schizophrenia. Unemployment rates, a higher risk of discrimination and stigmatization, and housing difficulties can be directly linked to challenges in accessing healthy food, a fact that is especially concerning for pregnant women with schizophrenia or mothers who must feed their children. Furthermore, other barriers increase the risk of nutritional deficiencies in schizophrenia , and therefore, the risk of developing medical comorbidities (Seeman, 2023). A recent review highlights that poor nutrition in women with schizophrenia is associated with factors such as poverty and social isolation, and may be related to disruptions in circadian rhythms, substance use, and living conditions.
In schizophrenia there is a relationship between nutrition, the expression of symptoms, the progression of the disorder and morbidity and mortality, in which the impact of social risk factors must be taken into account.
That is why, in our unit, we are developing nutrition and food groups focused on meaningful learning experiences, in which the women we serve are offered different tasks and activities focused on:
- Food knowledge.
- Understanding the nutrients present in food.
- The application of the information learned about food/nutrients.
- The analysis of different menu proposals.
- The evaluation.
- The creation of specific plans by the people being served.
Women with severe mental illness have worse physical health
There are many ways to classify food, some based on its origin and others on its nutrient content. Based on the size of the nutrients, they are divided into macronutrients (carbohydrates, proteins, and lipids) and micronutrients (minerals and vitamins) (Morris, 2024). Foods are primarily divided into: fruits, vegetables, grains, proteins, and dairy products.
Fruit
Fruits have beneficial effects, such as their antioxidant and anti-inflammatory properties, and they also possess antihypertensive properties. These effects have been associated with a decrease in the rates of cardiovascular disease and some types of cancer (Amiot-Carlin, 2019). Some studies have found that adding an extra serving of fruit to one's diet can reduce overall cardiovascular risk. Fruits are rich in vitamins B and C, minerals, and carotenoids, and these nutrients are largely responsible for their antioxidant effect.
Some studies have found that adding an extra portion of fruit to your diet can reduce your overall cardiovascular risk.
In women with schizophrenia, given the rates of cardiovascular and respiratory diseases and cancer mortality, the recommendation of nut consumption is crucial (Natividad et al., 2023). On the other hand, nuts, especially walnuts , have cardioprotective properties that contribute to the prevention and improvement of cardiovascular diseases. Several studies indicate that the incidence of cardiovascular events decreases in people who follow a Mediterranean diet with extra virgin olive oil or walnuts (Estruch et al., 2018). Focusing on mortality risk, walnut consumption has been associated with a protective cardiovascular effect and a reduction in cancer mortality.
Vegetables
Consuming vegetables, which are rich in fiber and have high concentrations of minerals and vitamins, reduces mortality from cardiovascular disease, cancer, and all causes (Aune et al., 2017). These findings are justified because vegetables regulate certain metabolic parameters, such as glucose, lipid, and blood pressure levels, and possess antioxidant properties that decrease the risk of cancer . Therefore, their consumption should also be recommended for women with schizophrenia, and this recommendation deserves special consideration within the context of our somatic morbidity and mortality observatory.
Cereals
Cereals are foods that are mainly classified as whole grains and refined grains, with the former being considered cardioprotective because they contain nutrients such as vitamins A, B1 (thiamine), B2 (riboflavin), B3 (niacin), B6 (pyridoxine), B9 (folate), and vitamin E. Their inclusion in dietary recommendations for women with schizophrenia should be considered.
Proteins
Protein-rich foods are a food group that includes meat, fish, eggs, beans, and nuts . Proteins can be obtained from plants or animals and contain amino acids that are essential for the proper functioning of the body. Consuming high-quality protein is crucial for optimal development and overall health, and helps prevent anemia and immune disorders , among other things (Wu, 2016). Some authors recommend increasing the consumption of plant-based proteins compared to animal-based proteins to reduce mortality risks.
Dairy
Dairy products, including milk, cheese, and yogurt, are foods and beverages that contain calcium, vitamin D, and protein, thus reducing the risk of osteoporosis and fractures. The nutrients and certain types of lipids in dairy have been shown to be cardioprotective and improve bone health (Rozenberg et al., 2016). Therefore, these foods should be especially considered for postmenopausal women with schizophrenia , as these women are at a stage of life with an increased risk of cardiovascular disease, osteoporosis, and bone fractures.
We must not forget that dietary and nutritional recommendations should be accompanied by monitoring of other lifestyle factors and comorbidities, and by analyzing the prescription of medications taken by these women, as well as psychosocial risk factors.
The literature describes the association between certain foods, endocrine disorders, and the risk of hyperprolactinemia, an endocrine disorder associated with amenorrhea (absence of menstruation) and an increased risk of osteoporosis, especially in postmenopausal women. It also emphasizes the need to adapt nutritional recommendations to the socioeconomic status of the individuals being served . Recommendations for extra virgin olive oil or walnut consumption should take into account that some women may face financial difficulties in ensuring their access to these foods. Peanut consumption, which is less expensive than walnuts, can be recommended since it has also been associated with a reduction in overall mortality and cardiovascular mortality in American and Chinese populations, as well as in vulnerable groups (Luu et al., 2015).
In conclusion, nutritional and dietary recommendations for women with schizophrenia must take into account their main comorbidities and mortality risk factors. Recommendations should aim to improve their metabolic and cardiovascular profile and enhance the antioxidant and anti-inflammatory effects of certain foods. The diet of women with schizophrenia is influenced by factors such as mental health, lifestyle, and the social determinants of health . The economic cost of some foods considered healthy should be considered in the recommendation process. In specialized units focused on the challenges of physical health, mental health, and psychosocial risk factors, nutritional interventions should aim to comprehensively improve the main health conditions or problems. Therefore, interventions should be multidisciplinary, geared towards meaningful learning or change for the women receiving care, and personalized at all times.
