nutrients

Review
The Role of Kiwifruit in Supporting Psychological Well-Being:
A Rapid Review of the Literature
Michael Billows 1,2 , Naomi Kakoschke 1 and Ian T. Zajac 1,2, *

1 Human Health, Health and Biosecurity, CSIRO, Adelaide 5000, Australia

2 School of Psychology, University of Adelaide, Adelaide 5000, Australia
* Correspondence: ian.zajac@csiro.au; Tel.: +61-88-303-8875

Abstract: Consumption of vitamin-rich fruits and vegetables is emerging as a recommendation for

the prevention and treatment of depression and anxiety. This review sought to examine literature in-
vestigating the role of kiwifruit in supporting psychological well-being in adult populations through
increased vitamin C intake. The literature search using CINAHL, Embase and PubMed databases
was restricted to English-language articles published from 2005 through July 2022. Inclusion criteria
were randomized trials that delivered kiwifruit interventions to adult populations assessing psycho-
logical well-being. Studies were assessed for bias using the Joanna Briggs Institute critical appraisal
tool for randomized controlled trials. The literature search identified two eligible trials involving
202 participants that delivered gold kiwifruit interventions and evaluated aspects of psychological
well-being (e.g., mood disturbance, vitality, vigour, depression). Daily consumption of two gold
kiwifruit was associated with significant reductions in mood disturbance and fatigue, and significant
increases in well-being and vigour. Larger effects were observed in participants with higher baseline
mood disturbance. Additional research involving a broader range of cohorts and isolating the effects
of other micronutrients within gold kiwifruit implicated in the pathophysiology of depression is
warranted. Overall, preliminary evidence suggests that daily consumption of two gold kiwifruit
Citation: Billows, M.; Kakoschke, N.;
might improve psychological well-being in adult populations.
Zajac, I.T. The Role of Kiwifruit in
Supporting Psychological Well-Being: Keywords: kiwifruit; mood; psychological well-being; vitamin C status
A Rapid Review of the Literature.
Nutrients 2022, 14, 4657. https://
doi.org/10.3390/nu14214657
1. Introduction
Academic Editor: Mary Catherine
DeSoto
1.1. Mental Health and Psychological Well-Being
The global burden attributable to depressive and anxiety disorders in adults is consid-
Received: 14 September 2022
erable with depressive and anxiety disorders ranked as the sixth and fifteenth leading cause
Accepted: 26 October 2022
of disability-adjusted-life-years (21.6 & 28.7 million respectively) in adults aged 25-49 years
Published: 3 November 2022
in 2019 [1,2]. Recognising the lifespan prevalence and the growing burden of depressive
Publisher’s Note: MDPI stays neutral disorders, between 1990 and 2019 depressive disorders rose from the nineteenth to the
with regard to jurisdictional claims in thirteenth leading cause of disability-adjusted-life-years across all ages [3]. The World
published maps and institutional affil- Health Organisation estimated that in 2015, 4.4% of the global population (322 million)
iations. were living with depression [4]. Twelve-month and lifetime prevalence rates of depression
in adults have been calculated at 7.2% and 10.8%, respectively, [5]. The psychosocial burden
on individuals living with depression is substantial including negative effects on quality of
life, activities of daily living, cognition and mood, employment status, mortality and inter-
Copyright: © 2022 by the authors.
personal relationships [6,7]. The financial cost associated with depression for individuals
Licensee MDPI, Basel, Switzerland.
and society are not inconsequential. In developed nations, health care costs for individuals
This article is an open access article
with depression can be 30% greater than those in the general population [8] and societal
distributed under the terms and
conditions of the Creative Commons
costs in the USA were estimated at USD326.2 billion in 2018 [6].
Attribution (CC BY) license (https://
Despite the high prevalence rates and level of disease burden wrought by depression,
creativecommons.org/licenses/by/ and seemingly at odds with our knowledge of the condition and efficacious treatments
4.0/). (e.g., pharmacotherapy and psychological interventions), the frequency of help-seeking

Nutrients 2022, 14, 4657. https://doi.org/10.3390/nu14214657 https://www.mdpi.com/journal/nutrients

Nutrients 2022, 14, 4657 2 of 14

rates remains concerningly low. Global estimates of the treatment gap for depression,
representing the difference between the prevalence of the disorder and the proportion of
individuals treated for depression, suggest more than half (56%) of all individuals with
depression do not receive any treatment [9]. A review paper examining the World Health
Organization’s World Mental Health Surveys reported that 56.7% of individuals with Major
Depressive Disorder identified the need for treatment [10]. Of these, 71.1% had attended
at least one visit to a service provider, however only 41% received treatment that satisfied
minimal standards.
Although depression is diagnosed and treated in health care settings, barriers ex-
ist to professional treatment delivery. Access to treatment providers, costs of treatment,
and demand for services that outstrip supply contribute to low levels of treatment and
high prevalence rates [10]. Fortunately, treatment for depression is not restricted to phar-
macotherapy and psychological interventions. Lifestyle factors such as regular exercise,
positive social supports, stress management, adaptive sleep hygiene behaviours and healthy
dietary patterns have been associated with reduced risk of depression and higher psycho-
logical well-being [11–13]. Moreover, many of these factors are accessible outside of formal
treatment pathways and allow the individual to exercise influence over their psychological
well-being. Supporting the positive consumer perception of the value of lifestyle factors in
moderating mental health outcomes, a recent national survey identified that almost 61% of
respondents took some form of self-initiated action to improve their psychological well-
being [14]. These actions included increasing their level of physical activity (37%), accessing
social supports (24%) and practising relaxation techniques (23%). Recognising growing
public interest in the effect of diet and nutrition on mental health outcomes, more than 20%
of respondents reported changing their diet and 15% initiated vitamin and supplement
intake to maximise their psychological well-being.

1.2. Diet and Psychological Well-Being

A recent randomized controlled trial (HELFIMED trial) examined the influence of a
Mediterranean-style diet, characterised by high intake of legumes, nuts, seeds, wholegrains,
fruit, vegetables and olive oil, supplemented with fish oil in adults with self-reported
depression [15]. Results at three months showed that adherence to the Mediterranean
diet was associated with increased consumption of fruit, nuts and vegetables and was
associated with reductions in symptoms of depression. A Mediterranean diet intervention
was also associated with improved self-reported quality of life and decreased depression
symptomatology in young males [16]. Offering another pathway to improved psychological
well-being, provision of nutrition education counselling (i.e., emphasising the benefits from
fruit and vegetable consumption and biological effects of active constituents such as vitamin
C) was associated with increased fruit and vegetable consumption, increases in plasma
vitamin C concentrations and improvements in quality of life in a community setting [17].
The consequences of inadequate fruit and vegetable intake on adult psychological
well-being are substantial. Population-based surveys have reported that higher fruit and
vegetable consumption was associated with reduced odds of experiencing an anxiety
or mood disorder, positive mental health, and greater psychological well-being [18,19].
Elsewhere, it has been reported that five serves of fruit and vegetables per day conferred
reduced risks of anxiety and cognitive impairment [20,21]. Longitudinal studies have
reported that increased fruit and vegetable consumption was associated with reduced
psychological distress and risk of depression, and increased well-being, life satisfaction
and happiness [22–25]. Thus, evidence to date suggests that dietary interventions, both
those that adopt specific food group or generalised approaches to improved dietary intake,
might offer useful adjunctive avenues for the prevention and treatment of common mental
health disorders and improve psychological well-being.
Nutrients 2022, 14, 4657 3 of 14

1.3. Vitamin C and Psychological Well-Being

In addition to considering the impacts of whole of diet and food-group approaches on
well-being and mental health, research has also considered the role of specific vitamins and
minerals. Vitamin C is one such micronutrient that has garnered significant attention in the
diet and well-being landscape. Vitamin C is a water-soluble micronutrient that humans,
along with only several other species, are unable to synthesize themselves despite having
an absolute requirement for vitamin C for a range of important biological functions [26].
The dialectical opposition between an absolute requirement for vitamin C and our species’
loss of ability to synthesise it, has been explained by the concept that our early ancestors
relied on diets rich in vitamin C which led to the eventual pruning of genes involved in
endogenous vitamin C synthesis [27]. Therefore, vitamin C must be obtained exclusively
from diet, principally through the consumption of fruits and vegetables [28]. Vitamin C
acts as an antioxidant and free radical scavenger and is an essential cofactor in numerous
enzymatic reactions including that of dopamine β-hydroxylase, an enzyme that is central to
the synthesis of adrenaline from dopamine. Vitamin C also acts as an essential cofactor in the
metabolism of tryptophan, a necessary requirement for the synthesis of serotonin [29–31].
Altered dopamine β-hydroxylase activity has been described in a range of psychiatric
conditions including mood and anxiety disorders and disorders of the digestive tract [32]
and acute tryptophan depletion has been associated with reduced serotonin levels and
lowered mood states [33]. Emerging work in the field of epigenetics indicates that vitamin
C contributes to epigenetic modifications in early development which in turn may influence
key psychological and physiological outcomes across the lifespan [34,35]. Reinforcing its
role in neurocognitive functioning, the highest concentrations of vitamin C in humans are
found in the brain and cerebrospinal fluid and vitamin C is preferentially retained in these
areas even when plasma and other organs in the body are depleted of vitamin C [36].
The relationship between vitamin C and psychological well-being in adult populations
has been examined through cross-sectional studies, albeit with mixed results. Depression
symptoms along with overall mood disturbance, anger and confusion were inversely
related to plasma vitamin C concentrations in a cross-sectional study of male tertiary
students [31]. In contrast, others have reported no significant associations between fatigue
and mood in a similar-aged cohort [37] nor in a cohort of healthy adults aged 50-years
old [28]. Heterogeneity of ethnicity may have contributed to the mixed results between
these studies [38]. Intervention studies delivering vitamin C in supplement form have also
returned mixed results. Acutely hospitalised elderly patients supplemented with 500 mg
vitamin C twice-daily for 7–14 days experienced reductions in mood disturbance scores and
psychological distress [29,39,40]. Healthy young adults supplemented with 1000 mg/day
vitamin C (3 x/day) for 14 days exhibited a reduced subjective stress response [41], and
500 mg/day supplementation of vitamin C was associated with mood improvements and
increased vigour in healthy adult males [42]. Conversely, no associations were found
between vitamin C supplementation and levels of fatigue or mood in healthy adults
supplemented with 1000 mg/day in a recent placebo-controlled trial [37]. Against the
backdrop of the established associations between adequate fruit intake, plasma vitamin C
concentrations and psychological well-being, the equivocal results from supplement studies
compels researchers to investigate whether mental health outcomes might be supported by
daily consumption of fruits that are recognised for their high vitamin C concentrations.

1.4. Kiwifruit
Kiwifruit, the commercial designation of plants from the genus Actinidia are a nutrient-
dense fruit that contain high levels of micronutrients including vitamins, minerals, proteins
as well as compounds such as phytonutrients, enzymes and other antioxidants [38]. Impor-
tantly, kiwifruit are recognised for their exceptionally high vitamin C content. The two most
commercially popular and studied varieties are Actinidia chinensis var. chinensis ‘Zesy002’
Zespri® SunGold and Actinidia deliciosa ‘Hayward’ kiwifruit (hereinafter referred to as
gold kiwifruit and green kiwifruit, respectively).
Nutrients 2022, 14, 4657 4 of 14

A growing body of research has demonstrated the putative health benefits associated
with gold and green kiwifruit consumption. Specifically, both varieties have positive
associations with digestive and metabolic health outcomes [43]. More recently, research has
begun to link potential benefits of gold kiwifruit consumption to improved psychological
well-being. A single serve (90 g) of gold kiwifruit delivers more than three times the
recommended daily intake of vitamin C for adults (45 mg/d) and contains almost 70%
more vitamin C than the green kiwifruit (137 mg & 79 mg respectively) [44,45]. When
judged against other commercially popular fruits, the vitamin C content of gold kiwifruit
easily surpasses the levels typically found in oranges (46.9 mg), strawberries (41 mg),
bananas (5 mg), blueberries (3.5 mg) and pineapple (22.5 mg) per single serve [45]. The
high vitamin C content of gold kiwifruit has it well-placed to serve as an important whole
food vector for the delivery of vitamin C, a micronutrient with established associations
with psychological well-being.

2. Aim of Review
The aim of this rapid review is to summarise the available literature from randomized
controlled trials that have examined the impact of kiwifruit interventions on psychological
well-being in adult populations

3. Method
3.1. Research Question
Does kiwifruit consumption support psychological well-being in adult populations
through increased vitamin C intake?

3.2. Design
This review was conducted in line with the Preferred Reporting Items for Systematic
Reviews and Meta Analyses (PRISMA 2020 statement) and PRISMA for abstracts [46,47]
with consideration given to applicability of PRISMA 2020 statement items to a rapid review.
The rapid review method was selected as the authors identified a priori that a paucity of
literature existed pertaining to the research question. Furthermore, it was recognised that
this style of review was well suited to introducing primary research articles, informing
clinical practise of the development of new treatments, and responding to specific research
questions, as was the case in the present article [48,49]. Rapid reviews have been shown to
produce similar results compared to systematic reviews, are rooted in the scientific method,
and can offer adequate advice for clinical decision-makers [50–52].

3.3. Inclusion/Exclusion Criteria

Eligibility criteria were determined using the PICO (population, intervention, com-
parisons and outcome) framework [53] and was arrived at through author consensus.
Studies were included if they were randomized controlled trials or observational trials of
adult (≥18 years of age) populations. Studies were selected if the active intervention was
identified as any form (i.e., whole fruit or kiwifruit-derived nutritional ingredients) of gold
or green kiwifruit, or if, in the case of observational studies, kiwifruit was identified as an
explanatory variable. Intervention studies that utilised a methodologically justifiable com-
parator (i.e., placebo or another dietary condition) were included. Studies were excluded if
they did not quantify the amount of kiwifruit consumed, delivered kiwifruit as part of a
larger intervention (i.e., Mediterranean Dietary Pattern), did not contain original data or if
results of the outcome(s) of interest were not measured or reported.
The primary outcome measure of interest was psychological well-being. Psychological
well-being was considered a catch-all term to encompass a range of constructs including
mood, psychological distress, depression, anxiety, stress, vitality, vigour and mood distur-
bance. Only studies that assessed psychological well-being with validated and reliable
psychometric assessment instruments were considered for inclusion. A secondary out-
come measure was improvements in vitamin C concentrations determined by validated
Nutrients 2022, 14, 4657 5 of 14

assessment tools (e.g., blood plasma pathology protocols). Studies that reported on vitamin
C concentrations but did not assess psychological well-being were excluded. Eligibility
criteria for inclusion was restricted to articles written in the English language and published
between 2005 to the date of the database search. Restricting the search to English-language
articles located in major bibliographic databases (Table 1.) can produce results comparable
to reviews using more comprehensive searches sans language restrictions and is considered
a viable methodological protocol for rapid reviews [54,55].

Table 1. Search terms (search conducted 5 July 2022).

Key Concept→
Kiwifruit Mental Health Vitamin C
↓Database (Platform)
MH “Mental health” OR MH Affect
MH Kiwi + OR TI “Kiwi fruit” OR OR MH Depression OR AB Vitality
AB “Kiwi fruit” OR TI Kiwifruit OR TI Vitality OR MH
OR AB Kiwifruit OR TI “Actinidia “Psychological well-being” OR TI
Deliciosa” OR AB “Actinidia “Psychological well-being” OR AB
Deliciosa” OR TI “Actinidia “Psychological well-being” OR TI
MH “Ascorbic acid” +
CINAHL with full text Chinensis” OR AB “Actinidia “Psychological well-being” OR AB
OR TI “Vitamin C” OR
(EBSCOhost) Chinensis” OR TI “Gold kiwifruit” “Psychological well-being” OR TI
AB “Vitamin C”
OR AB “Gold kiwifruit” OR TI “Psychological distress” OR AB
“Green kiwifruit” OR AB “Green “Psychological distress” OR TI
kiwifruit” OR TI Zesy002 OR AB “Mood disturbance” OR AB “Mood
Zesy002 OR TI Sungold OR AB disturbance” OR TI “Mood
Sungold AND improvement” OR AB “Mood
improvement” AND
exp Mental health OR Mental
exp Kiwifruit OR Kiwi fruit.ti,ab health.ti,ab OR exp Affect OR
OR Kiwifruit.ti,ab OR exp Affect.ti,ab OR exp Mood OR
Actinidia OR exp Actinidia Mood.ti,ab OR exp Depression OR
chinensis OR Actinidia Depression.ti,ab OR Vitality.ti,ab
chinensis.ti,ab OR exp Actinidia OR exp Psychological well-being exp Ascorbic acid OR
Embase (Ovid)
deliciosa OR Actinidia OR exp Psychological well-being Vitamin C.ti,ab
deliciosa.ti,ab OR Gold OR Psychological well-being.ti,ab
kiwifruit.ti,ab OR Green OR Psychological well-being.ti,ab
kiwifruit.ti,ab OR Zesy002.ti,ab OR Psychological distress.ti,ab OR
OR Sungold.ti,ab AND Mood disturbance.ti,ab OR Mood
improvement.ti,ab AND
“Mental health” [mh] OR Mental
health[tiab] OR “Affect” [mh] OR
Kiwi fruit[tiab] OR Kiwifruit[tiab] Affect[tiab] OR Mood[mh] OR
OR “Actinidia” [mh] OR Mood[tiab] OR “Depression” [mh]
Actinidia deliciosa[tiab] OR OR Depression[tiab] OR
“Ascorbic acid” [mh] OR
PubMed (NCBI) Actinidia Chinensis [tiab] OR Vitality[tiab] OR Psychological
Vitamin C [tiab]
Gold kiwifruit[tiab] OR Green well-being[tiab] OR Psychological
kiwifruit[tiab] OR Zesy002[tiab] well-being[tiab] OR Psychological
OR Sungold[tiab] AND distress[tiab] OR Mood
disturbance[tiab] OR Mood
improvement[tiab] AND

3.4. Databases
Multiple databases (interface/platform) were utilised in the literature search to max-
imise integrity of the review [48]. CINAHL with full text (EBSCOhost), Embase (Ovid) and
PubMed (NCBI) were searched on 5 July 2022.

3.5. Search Terms

The key concepts identified in the research question (Kiwifruit, mental health, and
vitamin C) were used to generate search terms developed by the first author. Final search
Nutrients 2022, 14, 4657 6 of 14

terms were arrived at via consensus following review and discussion between MB and
co-authors, NK and IZ. Two studies [56,57] previously identified as pertinent to the re-
search question were reviewed for key words to support formulation of search terms. An
experienced and qualified librarian was engaged to help develop the search strategy and
identify suitable databases and a basic logic grid was created and applied to the individual
databases. Search terms (Table 1) remained consistent across databases with adjustments
made to reflect differences in subject headings, field codes and truncations used within each
database. The three key concepts were combined with AND in the search (i.e., Kiwifruit
AND Mental health AND Vitamin C) to ensure that results mentioned all key concepts in
the same article. The first author was responsible for undertaking the database search.

3.6. Screening
Title, abstract and full text screening of articles were completed by the first author.

3.7. Critical Appraisal

The first author was responsible for critical appraisal of the selected studies. Stud-
ies were appraised using the Joanna Briggs Institute (JBI) critical appraisal checklist for
randomized controlled trials [58].

4. Results
4.1. Search Outcomes
Nutrients 2022, 14, xTwenty-two
FOR PEER REVIEWarticles
were captured in the initial search of the databases (CINAHL
7 of 15

(n = 3), Embase (n = 11) and PubMed (n = 8). The study selection process is summarised in
the PRISMA flowchart (Figure 1). The citations were exported and combined into a single
library using Endnote 20 software [59]. Full-text documents were retrieved for all articles.

Articles identified from database search N = 22:

Identification

CINAHL Embase PubMed

n=3 n = 11 n=8

Duplicates removed n = 9
Screening

Titles screened n = 13

Articles excluded after title

screen n = 8
Eligibility

Full text screened n = 5

Articles excluded after full
text screen n = 3:

Commentary n = 1
Summary n = 1
Inclusion

Unrelated to kiwifruit n = 1
Articles for inclusion n = 2

Figure 1. PRISMAFigure
flow 1.
diagram
PRISMA of rapid
flow review.
diagram of rapid review.

After the removalAfterofthe

duplicates
removal of (n = 9), thirteen
duplicates articles
(n= 9), thirteen remained
articles remained for
fortitle
title screening.
screening.
Of these,
Of these, eight were eight were
assessed as assessed as irrelevant
irrelevant to the research
to the research question
question and and excluded. Five
excluded. Five
assessed kiwifruit micronutrient profiles or kiwifruit harvesting outcomes [59–63], one
assessed kiwifruit micronutrient profiles or kiwifruit harvesting outcomes [60–64], one
addressed chemotaxis and oxidant generation in humans [64], another examined the im-
addressed chemotaxis and oxidant
pact of functional generation
foods on bone health in humans
[65], and one [65],
article another examined
was identified the
as a study
impact of functional foods that
methodology on bone health
considered the [66], and one
relationship article
between was and
kiwifruit identified asThree
sleep [66]. a study
of
the remaining five articles were removed following full-text screening. These included an
article identified as a commentary on one of the other articles [67], an article providing a
summary of studies that examined nutritional intake and neurocognitive health [68], and
a cross-sectional study that examined the relationship between blood plasma vitamin C
status and psychological well-being without kiwifruit specificity [38]. The remaining two
Nutrients 2022, 14, 4657 7 of 14

methodology that considered the relationship between kiwifruit and sleep [67]. Three of
the remaining five articles were removed following full-text screening. These included an
article identified as a commentary on one of the other articles [68], an article providing a
summary of studies that examined nutritional intake and neurocognitive health [69], and
a cross-sectional study that examined the relationship between blood plasma vitamin C
status and psychological well-being without kiwifruit specificity [38]. The remaining two
articles [56,57] were assessed as eligible for inclusion and critical appraisal.

4.2. Critical Appraisal

The included articles by Carr et al. [57] and Conner et al. [56] satisfied more than half
(9 and 8 items, respectively out of 13 items) of the criteria on the JBI appraisal tool and were
deemed suitable for inclusion in the review. Both studies failed to satisfy checklist criterion
related to the blinding of participants and researchers, an issue regularly encountered in
clinical trials delivering whole-food interventions [70].

4.3. Description of Included Studies

A summary of the studies included is provided at Table 2.

Table 2. Summary of included studies.

Primary
Study
Citation Participants Study Design Intervention Outcome Main Findings
Timeline
Measures
Trend toward decrease in
TMD (p = 0.06) and
depression (p = 0.06) in
2 kiwifruit condition. No
effect in 12 kiwifruit
condition. Participants in
Experimental
1 2 kiwifruit condition with
with 2 kiwifruit/d
Males (n = 35), 5-wk lead-in, higher baseline TMD
Carr et al. randomized (n = 18), POMS–TMD;
Mean age = 6-wk experienced decrease in
(2013) [52] parallel-arms, 2 kiwifruit/d plasma vitamin C
21 ± 3 years intervention TMD (p = 0.03), decrease in
no control (n = 17)
fatigue (p = 0.05), increase in
group
vigour (p = 0.02) and trend
(p = 0.07) toward decrease in
depression. Significant
increase (p < 0.0001) in
venous vitamin C in both
conditions.
Decrease in TMD (p = 0.03)
in kiwifruit condition.
Increase in well-being in
2 Gold
kiwifruit (p = 0.02) and
kiwifruit/d
Males and Randomized supplement condition
(n = 57),
females placebo- 2-wk lead-in, (p = 0.09). Decrease in
1 Vitamin C POMS-SF TMD;
Conner et al. (n = 167, 61% controlled 4-wk fatigue (p = 0.052) at week 2
supplement/d MFSI; WEMWBS;
(2020) [51] female), experimental intervention, of intervention in kiwifruit
(n = 56), plasma vitamin C
Mean age = design with 2-wk washout condition. Increase in
1 Placebo
21 ± 3 years comparator venous vitamin C
tablet/d
(p < 0.0001) in kiwifruit and
(n = 54)
supplement condition(s).
No effects observed in
placebo condition.
POMS-SF = profile of mood states-short form (35-item), TMD = total mood disturbance, MFSI = multi-dimensional
fatigue symptom inventory, WEMWBS = Warwick Edinburgh mental well-being scale, POMS = profile of mood
states (65-item).

Carr et al. [57] investigated the potential mood-enhancing properties of gold kiwifruit
in young adult males (N = 35) with sub-optimal vitamin C concentrations at screening using
a parallel-arms design. Participants were randomized to receive either one half of a gold
kiwifruit per day or 2 gold kiwifruit per day across a 6-week intervention period following
a 5-week lead-in. Psychological health as indicated via mood (65-item POMS) and plasma
Nutrients 2022, 14, 4657 8 of 14

vitamin C assessment was completed at baseline and at the end of the intervention period.
Following the intervention, participants (n = 17) supplemented with 2 gold kiwifruit per
day displayed a trend towards a 35% decrease in total mood disturbance (p = 0.061) and
depression (p = 0.063) on the POMS. A sub-group analysis of participants (n = 8) in the two
kiwifruit/d condition with higher-than-average baseline total mood disturbance revealed
a 38% decrease in mood disturbance (p = 0.029), a 38% decrease in fatigue scores (p = 0.048),
a 31% increase in vigour (p = 0.023) and a 34% decrease in depression trending toward
significance (p = 0.075). No effect on mood scores was observed in participants (n = 9) in
the two kiwifruit/d condition with lower-than-average baseline total mood disturbance
scores. Analysis of participants (n = 18) in the 12 kiwifruit per day condition revealed no
effect of the intervention on mood outcomes. Plasma vitamin C concentrations increased
significantly in both the low-dose and high-dose conditions following the intervention;
however, a 15-fold increase in urinary vitamin C excretion was observed in the high-dose
condition suggesting plasma ascorbate saturation for the high-dose group only.
Conner et al. [56] employed a randomized, placebo-controlled trial examining the
effects of gold kiwifruit on psychological well-being and subjective vitality. Young adults
(N = 167, 61% female) aged 18–35 years with sub-optimal plasma vitamin C (<40 µmol/L)
were randomized to receive either 2 gold kiwifruit per day, a daily 250 mg vitamin C supple-
ment or a placebo tablet (1 tablet/day) across the 28-day intervention period, book-ended
by two-week lead-in and two-week washout periods. Participants completed psychological
well-being (POMS-SF, MFSI & WEMWBS) and fasting plasma vitamin C assessments at
fortnightly intervals throughout the 8-week trial. Participants who consumed gold ki-
wifruit reported significant (p = 0.03) improvements in mood and well-being during the
intervention period; and well-being improvements (p = 0.02) persisted during washout.
Participants in the supplement condition exhibited non-significant improvements in well-
being and decreased fatigue across the intervention period. Participants in the kiwifruit
and supplement conditions returned significant improvements in plasma vitamin C. No
effects on any outcomes were observed in the placebo condition.

5. Discussion
The purpose of this review was to identify and describe studies that have examined
the potential role of kiwifruit in supporting psychological health and well-being in adult
populations. The review identified a very small but promising body of work that provided
preliminary evidence of benefits to psychological well-being from consumption of gold
kiwifruit. The search did not reveal any studies that had examined the effect of green
kiwifruit on psychological well-being. This is not surprising given the substantial difference
in vitamin C concentrations between the green and gold cultivars (79 mg and 137 mg
per 90 g serve, respectively) and the recognised links between vitamin C intake and
mental health [37,44]. The primary findings reported in the studies identified in the review
were that consumption of gold kiwifruit tended to improve overall mood in young adult
males with sub-optimal vitamin C concentrations and moderate mood disturbance [57];
and that vitamin C intake via gold kiwifruit improved subjective vitality, and conferred
additional benefits compared to a vitamin C supplement in adults with suboptimal vitamin
C status [56].
Strengths of the two studies [56,57] in the current review included the use of validated
and reliable measures of psychological well-being and plasma vitamin C concentrations,
recruiting participants with sub-optimal vitamin C levels, comprehensive screening proto-
cols, lead-in periods to stabilise dietary intake, and intervention periods of sufficient length
to assess reliable indices of change from the intervention. The findings in Conner et al. [56]
are strengthened by the inclusion of a placebo and comparator group, as well as multiple
assessment timepoints across the trial. Nevertheless, the generalisability of results from
the two studies is limited by several factors. These include the small sample size (N = 35)
of young adult males and the small sample size (n = 8) included in sub-analyses [57],
restricting recruitment to otherwise healthy adults aged 18–35 years old [56,57] and lack of
Nutrients 2022, 14, 4657 9 of 14

a washout period [57]. Furthermore, micronutrients (i.e., folate, zinc, selenium, magnesium
and serotonin) found in gold kiwifruit that have been implicated in the pathophysiology
of depression [71–74] were not isolated or measured by either study, leaving the potential
relative contribution to mood outcomes from these nutrients undetermined.
As with most whole food nutrition trials, blinding of participants and researchers
to condition allocation is virtually impossible [71] and both studies were not immune to
this challenge. One study [56] did incorporate double-blinding, but only between the
placebo and comparator conditions and not in the active intervention. Non-blinding is-
sues notwithstanding, and although not directly addressed by Carr et al. [57], the authors
may have nullified any placebo effect with the inclusion of the low-dose intervention
condition. Delivering an intervention at non-therapeutic levels is an established method-
ology to isolate the curative agent as the only difference between the groups receiving
the intervention [75,76]. Carr et el. [57] recruited participants with sub-optimal vitamin
C levels (≤50 µmol/L) and delivered 53 mg of vitamin C to participants in the low-dose
condition, well below the estimated intake (83.4 mg) required to achieve optimal plasma
concentrations (>50 µmol/L) [77]. Results support the authors’ choice to deliver 53 mg
as the non-therapeutic dose with results demonstrating that although vitamin C concen-
trations increased significantly between baseline and post-intervention in the low-dose
condition, participants remained vitamin C-deplete (46 µmol/L) at the end of the trial.
Similar, non-therapeutic effects have been reported in other studies delivering 50 mg as a
low-dose vitamin C intervention [78]. Others [79] have taken issue with the randomization
protocols used by Conner et al. [56] and proposed that a mix of randomisation methods
were employed (i.e., stratification and block randomisation), and that some participants
were not randomly allocated to groups thereby reducing the strength of causal inferences
that might be drawn from results.
Generalisability of results to other populations (e.g., adults 35+ years, non-students,
adults with moderate mood disturbance or different ethnicities) remains problematic.
Applicability of results to both sexes remain limited as only one of the studies [56] included
female participants. Taken together, results from Carr et al. [57] and Conner et al. [56]
highlight the potential mood and vitality-enhancing properties of gold kiwifruit and
offer a tantalising taste of its utility as a whole-food vector for vitamin C delivery in
some adult populations. The differences in effects observed between whole-food and
supplement-delivered vitamin C suggest that there are quantifiable, additional benefits
from whole fruit over-and-above those conferred by supplements in otherwise healthy
adults [56]. Likewise, the enhanced mood and vitality outcomes observed in individuals
with greater psychological distress demand further attention and greater individuation of
the therapeutic benefits of the panoply of nutrients found in gold kiwifruit.
The scarcity of research exploring the relationships between kiwifruit and psychologi-
cal well-being offers a range of possibilities for future research. First, given the significant
burden of mental illness, it is necessary to replicate the current findings in larger ran-
domized controlled trials involving participants with elevated psychological distress and
sub-optimal vitamin C status. Second, opportunity exists to extend research to include
child, adolescent, middle-aged and elderly cohorts. Third, given the burden of mental
health disorders globally, preliminary evidence of benefits of kiwifruit consumption on
psychological health should be extended to populations with clinical or at least sub-clinical
symptoms of psychopathology to examine potential benefits of increased kiwifruit con-
sumption, and therefore vitamin C intake, on mental health symptoms and psychological
well-being. This is particularly important because the overall influence of kiwifruit on
mood outcomes may depend on severity of underlying mental health conditions. Fourth,
emerging concepts at the nexus of epigenetics and nutrition such as the influence of diet
and nutrient intake in epigenetic regulation and individual differences in response to
hypo-nutrition warrant ongoing investigation of the role of essential micronutrients, such
as vitamin C, on physiological and psychological outcomes. This would support the de-
Nutrients 2022, 14, 4657 10 of 14

velopment of dietary patterns that could inform individual-specific dietary management

strategies to promote life-long psychological well-being.
Whilst Vitamin C has been defined as a putative pathway for the observed benefits
of kiwifruit intake, this hypothesis does not preclude other nutritional aspects that may
contribute to observed effects. Future studies would benefit from investigating the indi-
vidual or synergistic contribution to psychological well-being from other micronutrients
found at dietary relevant levels in gold kiwifruit with established links to depression
pathogenesis [71–74]. For example, gold kiwifruit contain nutritionally relevant levels of
vitamin E, a micronutrient linked to mood regulation [80] and thought to act synergistically
with vitamin C in an antioxidant capacity [81]. Furthermore, examination of other miner-
als and micronutrients endogenous or exogenous to kiwifruit that possess a synergistic
relationship with vitamin C is warranted. For example, the bioavailability of iron, a trace
element essential for serotonin and dopamine synthesis [82] and implicated in alterations
in mood and behavior [83], is enhanced by vitamin C intake. Indeed, preliminary research
has already reported that consumption of gold kiwifruit with an iron-fortified meal im-
proved iron status in women with low iron stores [84]. Although not measured in the
studies included in this review, gold kiwifruit may confer indirect benefits to psychological
well-being through other vectors. The dietary fibre in kiwifruit is recognised as a natural,
palatable remedy for improving gastrointestinal function and laxation markers in some
populations [85]. Recent research has identified that gold kiwifruit intake increased bowel
frequency and reduced markers of gastrointestinal discomfort (e.g., bloating, indigestion)
in constipation-compromised adults [86,87]. Given the association between dietary fibre in-
take and the risk for development of depression [88], the examination of indirect pathways
to improving psychological well-being offered by gold kiwifruit may prove fruitful.
The strength of this review is reinforced by utilising multiple databases in the initial
search, an extensive and rigorous suite of selection criteria, use of a librarian in the formula-
tion of the search strategy, and three-author consensus of selection criteria and search terms.
In line with recommendations of the Cochrane Rapid Reviews Methods Group, restricting
articles to English-language only was considered a practical and viable methodology and
one which would not necessarily affect overall conclusions [54]. To support review rigour,
manual screening of the reference list of the two studies included in the review was also
undertaken to detect any missed studies omitted from electronic searching.
Although author consensus determined final search terms, the ensuant articles were
screened for title, abstract and full text, and were submitted for critical appraisal by a
single-reviewer (MB). Conclusions offered by the review or suggestions for future research
are naturally limited by the small sample size and heterogeneity between the studies.
Future reviews in this field will be assisted by an increased volume of research. Imposing
a restriction to publication date (2005 to July 2022) may have led to some articles being
missed [54]. The decision to establish a publication date restriction was taken however,
given a priori knowledge that research in this area is in its chronological infancy.

6. Conclusions
The aim of this review was to examine the available literature from randomized
controlled trials and intervention studies that have investigated the associations between
kiwifruit and psychological well-being in adult populations. This review is the first to
examine the discrete relationship between kiwifruit, recognised for its exceptionally high
vitamin C concentration, and psychological well-being. Results from the two studies
concord with previous research that has equivocally established the relationships between
vitamin C intake and mental health. Despite the small number of studies included in the
review, results warrant further investigations across an expanded range of cohorts and
settings to further determine the impact of gold kiwifruit on psychological well-being.
Recognising the impact of diet, and in particular whole fruit, on not only physiological, but
psychological health, gold kiwifruit may yet take its place within a clinical framework as
Nutrients 2022, 14, 4657 11 of 14

an appetising option within the dietary intervention space in the prevention and treatment
of depression.

Author Contributions: Conceptualization, M.B., N.K. and I.T.Z.; methodology, M.B., N.K. and I.T.Z.;
validation, M.B., N.K. and I.T.Z.; investigation and formal analysis, M.B.; supervision, I.T.Z.; Writing—
Original draft preparation, M.B.; Writing—Review and editing, M.B., N.K. and I.T.Z. All authors have
read and agreed to the published version of the manuscript.
Funding: This research was co-funded by Zespri International Ltd., The Commonwealth Scientific
and Industrial Research Organization (CSIRO) and the University of Adelaide.
Acknowledgments: The authors acknowledge the Traditional Owners of the land, sea and wa-
ters, of the area that they live and work on across Australia. The authors acknowledge the Tra-
ditional Owner’s continuing connection to their culture, and we pay our respects to their Elders
past and present.
Conflicts of Interest: MB—receives a PhD scholarship co-funded by Zespri International Ltd., Mount
Maunganui, New Zealand. NK—declares no conflict of interest with respect to this article. IZ—
declares no conflict of interest with respect to this article. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the
decision to publish the results.

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