Diet and ADHD

In ADHD, Fitness/Health, School Psychology on Wednesday, 12 September 2012 at 07:24

Healthy vs Western Diet Linked to Better Outcomes in ADHD

Megan Brooks & Penny Murata, MD


Clinical Context

In children with attention-deficit/hyperactivity disorder (ADHD), the effectiveness of diet and dietary supplements is not clear. Dietary measures that have been proposed include sugar restriction; the additive- and salicylate-free Feingold diet; the oligoantigenic or elimination diet; and ketogenic, megavitamin, and polyunsaturated fatty acid (PUFA) supplements. In the July 2011 issue of the Journal of Attention Disorders, Howard and colleagues reported a link between ADHD and a “Western” diet high in fat, refined sugars, and sodium.

This review of the literature assesses the evidence for dietary treatment in children with ADHD.

Study Synopsis and Perspective

When drug therapy fails to control ADHD or is unacceptable, adopting a “healthy” diet, eliminating items known to predispose to ADHD, and adding omega-3 fatty acid supplementation may be worth trying, new research suggests.

“The recent increase of interest in this form of therapy for ADHD, and especially in the use of omega supplements, significance of iron deficiency, and the avoidance of the ‘Western pattern’ diet, make the discussion timely,” the authors write.

Many parents and physicians continue to be interested in how diet and dietary changes, particularly parents wanting to find an alternative to stimulant medication or a complementary therapy. Nevertheless, it remains a “controversial” topic, the authors note.

For their review, J. Gordon Millichap, MD, and Michelle M. Yee, CPNP, from Children’s Memorial Hospital in Chicago, Illinois, searched PubMed for relevant studies on the role of diet and dietary supplements for the treatment of children with ADHD.

They note that their recommendations on diet and dietary supplements are based on a critical review of the data and their own experience in a neurology clinic for children and adolescents with ADHD.

The study was published online on January 9 in Pediatrics.

Elimination Diets Not Advisable

Perhaps the “most promising and practical” complementary or alternative treatment, write Dr. Millichap and Ms. Yee, is adopting a “healthy” dietary pattern, omitting items shown to predispose to ADHD or to make the condition worse. These items include fast foods, red meat, processed meat, potato chips, high-fat dairy foods, and soft drinks.

They point to a “provocative” study published last year, which found a link between ADHD in adolescents and a “Western-style” dietary pattern that was high in fat, refined sugars, and sodium and low in fiber, folate, and omega-3 fatty acids (Howard et al, J Atten Disord. 2011;15:403-411). ADHD was not associated with a “healthy” dietary pattern rich in fish, vegetables, fruit, legumes, and whole-grain foods.

Adopting a healthy dietary pattern “may offer an alternative method of treatment of ADHD and less reliance on medications,” the authors of the current study write.

They also note that although many parents report worsening of hyperactivity symptoms after consumption of foods and drinks containing sugar or aspartame — and isolated reports support the parents’ observations — most controlled studies have failed to find a significant harmful effect of sugar or aspartame, the authors note.

Additionally, they say that the elimination of sugar and aspartame and adapting additive-free diets are complicated, disruptive, and often impractical; such measures are indicated only in select cases.

Fatty Acid Supplements May Be Helpful

Low levels of long-chain PUFAs have been reported in the plasma and red cells of children with ADHD in comparison with their ADHD-free peers, Dr. Millichap and Ms. Yee note. Some studies have demonstrated a reduction in ADHD symptoms with PUFA supplementation, although no definitive conclusions can be drawn.

However, the authors note that “on the basis of reports of efficacy and safety, we use doses of 300 to 600 mg/day of omega-3, and 30 to 60 mg/day of omega-6 fatty acids, continued for 2 or 3 months, or longer if indicated.”

“As initial or add-on therapy, we have occasional reports of improved school grades and lessening of symptoms of ADHD, without occurrence of adverse effects. Most parents are enthusiastic about trying the diet supplements, despite our explanation of only possible benefit and lack of proof of efficacy,” they note.

They also note that iron and zinc supplementation is advisable when there is a known deficiency in these minerals, and this may “enhance the effectiveness” of stimulant therapy.

Pediatrics. Published online January 9, 2012.

Related Link
The National Institute of Mental Health’s Attention Deficit Hyperactivity Disorder (ADHD) site offers a wide range of information helpful for parent education including a downloadable booklet discussing the condition and its management.

Study Highlights

  • This review study provides an overview of the role diet has in children with ADHD. The following supplements, foods, and diets affect the children’s health outcomes in various ways, according to several studies.
  • Omega-3 and omega-6 fatty acid supplements
    • Low long-chain PUFA levels were reported in children with ADHD vs control patients.
    • Some studies showed that PUFA reduced ADHD symptoms, but other studies did not.
    • Doses of omega-3, 300 to 600 mg/day, and omega-6, 30 to 60 mg/day, for 2 to 3 months or longer have been used.
    • Concurrent ADHD medication is almost always needed.
  • Additive and salicylate-free (Feingold) diet
    • Adherence to the diet is complicated and may be disruptive or impractical.
    • Foods to be avoided are apples, grapes, luncheon meats, sausage, hot dogs, and cold drinks with artificial flavors and coloring agents.
    • Permitted foods are grapefruit, pears, pineapple, bananas, beef, lamb, plain bread, certain cereals, milk, eggs, and color-free vitamins.
    • Controlled trials found a small subgroup of preschool children had an adverse response to challenges of additives and preservatives.
    • Children with ADHD and atopy vs no atopy have a higher response to elimination of foods, artificial colorings, and preservatives.
  • Oligoantigenic (hypoallergenic/elimination) diet
    • Adherence to the diet is complicated and may be disruptive or impractical.
    • The oligoantigenic diet eliminates sensitizing food antigens or allergens, including cow’s milk, cheese, wheat cereals, egg, chocolate, nuts, and citrus fruits.
    • Elimination of some foods appeared to decrease some ADHD symptoms, but plays an uncertain role in ADHD treatment.
    • A 2- to 3-week period of elimination diet is followed by the reintroduction of single items each week until the food sensitivity is identified.
    • Behavior improvements might not occur for up to 2 weeks.
    • Enzyme-potentiated desensitization might enable children to become tolerant of provoking foods.
  • Sugar and aspartame
    • Sugar does not affect behavior or cognitive performance, but might affect a subset.
    • In preschool boys, daily sucrose and total sugar intake correlated with duration of aggression.
    • Reactive hypoglycemia after sugar load might reduce cognitive function.
    • Hypoglycemia is linked with impaired electrical activity of the cerebral cortex and slow rhythms on electroencephalogram.
  • Ketogenic diet
    • A ketogenic diet high in fats and low in carbohydrates for children with intractable seizures helped to control seizures and improve behavior, attention, and social functioning.
  • Iron deficiency
    • Iron deficiency is not consistently linked with ADHD severity or frequency.
    • 1 study showed that low serum ferritin correlated with baseline inattention, hyperactivity, impulsivity, and effective amphetamine dose needed.
  • Zinc deficiency
    • Low zinc levels were found in the serum, red cells, hair, urine, and nails of children with ADHD, but mostly in countries with endemic zinc deficiency.
    • In the United States, low serum zinc was linked with inattention, but not with hyperactivity or impulsivity.
    • Zinc supplements might enhance the effect of d-amphetamine, but are not routinely recommended.
  • Other alternative dietary therapies
    • Orthomolecular medicine and megavitamin therapy refer to combination of minerals and nutrients.
    • A study of megavitamin therapy in children with ADHD showed no improvement in behavior, but 42% had elevated serum transaminase levels.
  • “Healthy” vs “Western” diet pattern
    • A cohort study of children from birth to age 14 years found a “Western” dietary pattern associated with ADHD diagnosis and a “Healthy” diet pattern not associated with ADHD diagnosis.
    • The Western dietary pattern includes fast foods, red and processed meats, potato chips, high-fat dairy products, and soft drinks.
    • The Healthy dietary pattern includes fish, vegetables, tomatoes, fresh fruit, whole grains, and low-fat dairy products.

Clinical Implications

  • Indications for dietary therapy in children with ADHD include medication failure or adverse reactions, patient or parental preference, mineral deficiency, and need for change from an ADHD-linked Western diet to an ADHD-free Healthy diet.
  • In children with ADHD, additive-free and elimination diets are time-consuming and disruptive, but might be indicated in selected patients; iron and zinc are indicated for deficiencies; omega-3 supplements have inconsistent effects; and a Healthy diet rich in fish, vegetables, fruit, legumes, and whole grains might be beneficial vs a Western diet of fast foods, red or processed meats, high-fat dairy products, soft drinks, and potato chips.

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