When was the last time you told someone that you were not okay? Not the polite “I’m fine, just tired,” but the honest version. If you cannot remember, you are not unusual; you are part of a much wider pattern.

In 2019, the World Health Organization estimated that 13,774 people died by suicide in South Africa. Of these deaths, 10,861, nearly four out of every five, were among men (1,2). In one survey, 70 percent of men identified financial anxiety as a major source of distress (3), reflecting the enormous burden created by financial pressure, uncertainty about work, and the deeply ingrained expectation that men should provide for others without showing vulnerability. The problem is not that men are suffering less; it is that many have become exceptionally good at hiding it. 

Depression Does Not Always Look Like Sadness

Most widely used depression screening tools were developed in mixed samples with a primary focus on prototypical internalising symptoms such as sadness, tearfulness, and hopelessness, which means that some of the ways in which men express distress may be less readily recognised (4,5). While many men experience recognised symptoms such as low mood and hopelessness, distress may also be expressed through irritability, anger, increased alcohol use, risk-taking, emotional withdrawal or excessive work. These behaviours are not unique to men, but social expectations around masculinity may make some men more likely to conceal sadness or avoid asking for help (6). 

The South African Depression and Anxiety Group (SADAG) has highlighted this pattern among South African men, noting that when sadness and vulnerability are discouraged, distress may emerge through anger, withdrawal, substance use or overwork long before anyone identifies it as depression (7). As a result, some men may remain undiagnosed, not because they are coping well, but because neither they nor the people around them recognise what they are seeing. 

This sits within a much broader pattern of poorer health outcomes among men. Globally, men live on average five years less than women (71 years compared to 76), and mortality rates are significantly higher. In South Africa, violence and alcohol compound this risk (8). In 2017, the country recorded a homicide rate seven times the global average, with 87 percent of victims being men, most aged 15–44, and alcohol linked to many of those deaths (9). Yet men are not always recognised as a vulnerable group within health policy and funding frameworks, despite clear evidence that many are being left behind.  

The Metabolic Connection

Mood does not exist in isolation from the body; endocrine, metabolic, and inflammatory pathways all play a role (10). Low energy, reduced libido, loss of muscle mass, and blunted mood overlap substantially between testosterone deficiency and depressive disorders, so the two can be difficult to distinguish in clinical practice without hormonal assessment. In men, low testosterone is associated with insulin resistance and type 2 diabetes, and insulin resistance and poor glycaemic control are in turn linked to lower circulating testosterone levels, suggesting a bidirectional relationship between glucose metabolism and the hypothalamic–pituitary–gonadal axis (11). 

That relationship extends beyond hormones. Depression is associated with a higher burden of metabolic disease, and metabolic dysfunction can contribute to fatigue, poor sleep, inflammation, and reduced quality of life (12). At the same time, living with depression can make it harder to eat well, exercise regularly, sleep consistently, or manage chronic conditions effectively. Together, these factors can create a cycle in which mood and metabolism reinforce one another. The evidence does not suggest that metabolic dysfunction causes every case of depression, but it does show that the two are closely intertwined, and that addressing metabolic health may form one useful part of a broader approach to mental wellbeing (13). 

Diet is part of this story. For some people, large fluctuations in blood glucose contribute to symptoms such as fatigue, difficulty concentrating, or irritability, although mood disorders cannot be explained by blood sugar alone. Diets high in ultra‑processed foods, including packaged snacks, sugary cereals, and fast food, are consistently associated with higher rates of depression and anxiety in observational studies (14). Chronic, diet‑related inflammation is thought to influence the brain through immune signalling pathways and has been implicated in dysregulated mood.

Researchers are increasingly examining whether low‑carbohydrate or ketogenic approaches could support mental health, especially when metabolic dysfunction is present. Several biological mechanisms have been proposed, including a steadier supply of energy to the brain, shifts in neurotransmitter activity, and reductions in inflammatory signalling. Early studies suggest that these diets may help stabilise mood in some adults with depression or anxiety, particularly in individuals with insulin resistance or poor glycaemic control. A 2023 systematic review reported preliminary signals of benefit while emphasising the small and heterogeneous evidence base (15). A recent mechanistic review in Nutritional Neuroscience outlined plausible pathways such as reduced glycaemic variability, lower inflammation, and a shift toward ketone‑based brain energy metabolism that could support mood regulation (15,16). 

Exercise Helps, But Nutrition Leads

Exercise has strong evidence as part of the prevention and treatment of depression, including support for resistance training (17). Nutrition deserves a place alongside it. Dietary interventions have produced modest improvements in depressive symptoms in some trials, although results vary and the evidence is stronger for overall dietary quality than for any single food or macronutrient prescription. A 2019 meta‑analysis of randomized controlled trials found that structured dietary improvement was associated with reductions in depressive symptoms compared to control conditions, reinforcing the potential of nutrition as an important part of mental healthcare  (18).

Building meals around minimally processed foods, adequate protein, vegetables, and healthy fats may support metabolic health while also providing nutrients needed for normal brain function. This does not mean that food can cure depression, but it does mean that nutrition should not be dismissed as irrelevant to how the brain and body function. Nutrition and exercise should therefore be viewed as complementary parts of care, alongside sleep, social connection, psychological support, and, where appropriate, medication. 

What This Means

Depression in men often hides behind irritability, withdrawal, or overwork. It is tangled up with hormones, metabolism, and lifestyle in ways that make it harder to spot, but there are practical places to begin. Improving the quality of the food you eat, reducing ultra-processed foods, moving regularly, and paying attention to sleep can all support physical and mental health 

Just as important is telling one person what is really happening. It does not need to be everyone; it only needs to begin with someone you trust. SADAG’s 24‑hour Cipla Mental Health Helpline at 0800 456 789 exists for exactly that moment before you are ready to say it to someone you know.

The numbers are not ambiguous. Men are not suffering less; they may simply be suffering in ways that are easier to overlook. Better nutrition will not solve every mental health problem, but it belongs in a broader conversation that includes metabolic health, movement, sleep, financial and social pressures, professional care, and the courage to tell someone when “fine” is no longer the truth. 

Lifestyle changes can help to build a stronger foundation, but they are not substitutes for professional assessment or treatment when depression persists, distress becomes severe or suicidal thoughts are present. Men have spent long enough being told to carry the weight quietly. Asking for help is not another failure to endure; it may be the first step towards feeling like yourself again. 

References

1. Africa Check. (2022, August 29). Graphic showing higher suicide rates among men in South Africa is accurate. Africa Check. https://africacheck.org/fact-checks/meta-programme-fact-checks/graphic-showing-higher-suicide-rates-among-men-south-africa 
2. World Health Organization. (2021). Suicide worldwide in 2019: Global health estimates. WHO. https://iris.who.int/bitstream/handle/10665/341728/9789240026643-eng.pdf
3. South African Federation for Mental Health. (2026, June 21). Why South Africa’s male suicide rate is a national crisis. Independent Online (IOL). https://iol.co.za/news/south-africa/2026-06-22-why-south-africas-male-suicide-rate-is-a-national-crisis 
4. Jabłonka, D., Łądkowska, M., Kossak, N., Modzelewski, S., & Waszkiewicz, N. (2026). Gender-Sensitive Depression Scales: A Review of Male-Specific Assessment Tools. Diagnostics (Basel, Switzerland), 16(6), 925. https://doi.org/10.3390/diagnostics16060925 
5. Möller-Leimkühler, A. M., Jackl, A., & Weissbach, L. (2022). Gendersensitives Depressionsscreening (GSDS) – Befunde zur weiteren Validierung eines neuen Selbstbeurteilungsinstruments [Gender-Sensitive Depression Screening (GSDS) – Further Validation of a New Self-Rating Instrument]. Psychiatrische Praxis, 49(7), 367–374. https://doi.org/10.1055/a-1615-8274
6. von Zimmermann, C., Hübner, M., Mühle, C. et al. Masculine depression and its problem behaviors: use alcohol and drugs, work hard, and avoid psychiatry!. Eur Arch Psychiatry Clin Neurosci 274, 321–333 (2024). https://doi.org/10.1007/s00406-023-01567-0 
7. South African Depression and Anxiety Group. (n.d.). Depression. South African Depression and Anxiety Group. https://www.sadag.org
8. University of Cape Town. (2025, August 13). Men are dying younger worldwide – UCT researcher calls for action. https://www.news.uct.ac.za/images/userfiles/downloads/media/2025_08_13_MenHealth.pdf 
9. Cornell, M. (2025). Men’s health policies: long overdue. Bulletin of the World Health Organization, 103(8), 515–516. https://pmc.ncbi.nlm.nih.gov/articles/PMC12321234/pdf/BLT.24.292925.pdf  
10. Hayes F. J. (2025). TESTOSTERONE AND INSULIN RESISTANCE IN MEN: EVIDENCE FOR A COMPLEX BI-DIRECTIONAL RELATIONSHIP. Transactions of the American Clinical and Climatological Association, 135, 297–305. https://pmc.ncbi.nlm.nih.gov/articles/PMC12323448/
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13. Marazziti, D., Arone, A., Palermo, S., Annuzzi, E., Cappellato, G., Chiarantini, I., Prete, L. D., & Dell’Osso, L. (2023). The Wicked Relationship between Depression and Metabolic Syndrome. Clinical neuropsychiatry, 20(2), 100–108. https://doi.org/10.36131/cnfioritieditore20230202 
14. Lane, M. M., Gamage, E., Travica, N., Dissanayaka, T., Ashtree, D. N., Gauci, S., Lotfaliany, M., O’Neil, A., Jacka, F. N., & Marx, W. (2022). Ultra-Processed Food Consumption and Mental Health: A Systematic Review and Meta-Analysis of Observational Studies. Nutrients, 14(13), 2568. https://doi.org/10.3390/nu14132568 
15. Mazloomi, S. N., Talebi, S., Mehrabani, S., Bagheri, R., Ghavami, A., Zarpoosh, M., Mohammadi, H., Wong, A., Nordvall, M., Kermani, M. A. H., & Moradi, S. (2023). The association of ultra-processed food consumption with adult mental health disorders: a systematic review and dose-response meta-analysis of 260,385 participants. Nutritional neuroscience, 26(10), 913–931. https://doi.org/10.1080/1028415X.2022.2110188 
16. Firth, J., Stubbs, B., Teasdale, S. B., Ward, P. B., Veronese, N., Shivappa, N., Hebert, J. R., Berk, M., & Sarris, J. (2020). Diet as a hot topic in psychiatry: A population‑based study of habitual dietary patterns and depression. BMC Medicine, 18, 97. https://pubmed.ncbi.nlm.nih.gov/30192082/ 
17. Hossain, M. N., Lee, J., Choi, H., Kwak, Y. S., & Kim, J. (2024). The impact of exercise on depression: how moving makes your brain and body feel better. Physical activity and nutrition, 28(2), 43–51. https://doi.org/10.20463/pan.2024.0015 
18. Firth, J., Marx, W., Dash, S., Carney, R., Teasdale, S. B., Solmi, M., Stubbs, B., Schuch, F. B., Carvalho, A. F., Jacka, F., & Sarris, J. (2019). The Effects of Dietary Improvement on Symptoms of Depression and Anxiety: A Meta-Analysis of Randomized Controlled Trials. Psychosomatic Medicine, 81(3), 265–280. https://doi.org/10.1097/PSY.0000000000000673