Dietary Interventions for Attention-Deficit/Hyperactivity Disorder

Ashley Walther

DSM-V Definition of ADHDPeople with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or

homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork,

eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities.Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games)

Prevalence: Children: 4-5% Adults: 4.7% worldwide

Causes: Genetic Environmental Psychosocial

Treatment: Typically multifaceted

Stimulant medications Behavior modification/psychotherapy Unconventional approaches

Nutritional interventions

Dietary Approaches A subset of individuals display

hypersensitivity to various food components

Overall healthy diet Essential fatty acids Specific micronutrients Avoid processed foods/sodium/saturated

fat/refined sugars

Hypersensitivity Allergic

Triggered by immune response Dopamine transporters causally linked to ADHD

Found in abundance on human T-cells Trigger secretion of immune regulatory cytokines

Children with ADHD have a higher rate of allergic disease 67.5% of children with ADHD test positive for allergies, vs. 45% of controls

Non-allergic May occur via immunoglobulin-independent histamine release from mast cells and

basophilic granulocytes

History of Research 1973: Dr. Benjamin Feingold developed

Kaiser-Permanente (K-P) Diet Free of all foods containing natural

salicylates as well as all artificial colors and flavors

Reported that 60-70% of his patients improved on this diet

Problems: No structured diagnosis, control groups or

double blind conditions Based on subjective data no

statistical analysis possible Meta-analyses of studies indicate that only

11-33% of children respond to diet Diet is difficult to follow, many kids dislike

it, and diet provides less calcium, riboflavin and vitamin C than baseline diets

Artificial Food Colors Small amounts of artificial

food colors can cause irritability, restlessness, sleep disturbances and impulsivity in children who are sensitive to them

In non-hyperactive samples, there is a smaller but still significant relationship between artificial food colors and hyperactivity Food manufacturers in the

United Kingdom have been forced to eliminate several artificial food dyes from their products

Elimination Diet Studies Phase 1: only a few hypoallergenic foods are consumed for

2-5 weeks  Avoid Consume

Additives All artificial colors, flavors and

preservatives

 

Milk Dairy (cow’s milk, cheese, yogurt, ice

cream)

Rice milk

Chocolate Chocolate  Grains Wheat, rye, barley Oats, rice, rice

cakes/crackers, rice noodles

Meats/Poultry/Fish/Eggs

Eggs, processed meats Unprocessed meats, poultry, fish

Fruits Citrus All other fruitVegetables Legumes (peanuts,

beans, peas, etc.), soy, corn, corn oil, corn

syrup

All other vegetables

Nuts Peanuts, peanut oil Walnuts, pecans, almonds, etc. (not

processed with peanut/soy oil)

Phase 2: if child responds to diet, gradually reintroduce foods suspected of producing behavioral response one at a time Approximately 70% of children have been shown to

respond to elimination diets

“Western” Diet and ADHD “Western” diet: high in saturated/total fat, sodium and

refined sugars, low in omega-3 fatty acids, folate and fiber “Healthy” diet: low in saturated fat, sodium and refined

sugars, high in omega-3 fatty acids, folate and fiber Consumption of western style diet and processed foods

associated with: Higher rates of ADHD diagnosis Impairment of memory/working memory, attention, inhibitory

control and reward processes possibly a result of long-term changes to neuron function

Hypothesized that high consumption of food additives in processed foods may interact with inadequate micronutrient intake to produce ADHD symptoms

Specific Nutrients Iron

84% of children with ADHD had serum ferritin levels >30 ng/mL vs. 18% of control group

Supplementation of 80 mg/day for 12 weeks associated with a significant reduction in ADHD symptoms

Zinc cofactor for dopamine metabolism Low zinc levels have been correlated with inattention based on

parent and teacher ratings Low levels of zinc in serum, hair, urine and nails of children

with ADHD Zinc supplements of 30mg/day for 8 weeks enhance the

effects of stimulant medication Lowered required dose by 37%

Polyunsaturated Fatty Acids Children received supplements for 12 weeks

400mg EPA 40mg DHA 60mg gamma-linolenic acid 80mg magnesium (2% RDA) 5mg zinc (50% RDA)

Results indicated significant improvements in attention, hyperactivity, impulsivity and emotional and behavioral problems

Supervising physicians recommended that 61% of participants continue taking the supplement

Special Considerations Because ADHD is a psychiatric disorder, treatment will

also involve physician/mental health provider Many take stimulant medications to manage symptoms

May be necessary to work with prescribing physician, particularly if recommending a restricted elimination diet

Those with food sensitivities will need individualized diets to omit the offending food(s) Depending on the food omitted, supplements may be

necessary to prevent deficiency Checking serum ferritin and zinc levels may be

recommended, and supplements for these and essential fatty acids may be warranted

Potential Difficulties Restricted elimination

diets are time consuming, difficult and are often not well tolerated by children Foods that produce

behavioral effects are typically frequently consumed and enjoyed

Avoiding artificial food additives can be difficult Necessary to educate

clients in reading ingredients

Provide lists of additives and “safe” foods

FD & C Number

Common Name

Type of Chemical

Shade Foods Containing

ColorBlue #1 Brilliant Blue Triphenylme

thaneBlue Beverages,

candy, baked goods,

ice cream, cereals

Blue #2 Indigotine Sulfonated Indigo

Dark Blue Beverages, Candy

Green #3 Fast Green Triphenylmethane

Blue-Green

Beverages, candy, gelatin,

jelliesYellow #5 Tartrazine Azo Dye Yellow Gelatin, candy,

chips, ice cream,

cereals, baked goods, pickles

Yellow #6 Sunset Yellow

Azo Orange Beverages, jam, sausages,

bakedgoods, candy,

gelatinCitrus Red

#2Citrus Red Azo Orange May only be

used on skins ofsome Florida

orangesRed #3 Erythrosine Xanthene

DyePink Candy, baked

goods, popsicles,

cerealsRed #40 Allura Red Azo Red Candy,

beverages, gelatin,pastries,

sausages, cereals

Orange B   Azo   Hot dog and sausage casings

only

Impulsivity can make following a prescribed diet difficult Children may experience difficulty in school and adults may

have a long history of academic, occupational or interpersonal problems Find a balance between empathy and challenging inconsistent behaviors

Substance Abuse and ADHD Rates of ADHD among active substance abusers

range from 14-33% Substance abuse can increase risk of nutrient

deficiencies May worsen symptoms or lead to

noncompliance

Obesity and ADHD Obesity:

With ADHD: 29.4% Control: 21.6%

Overweight: With ADHD: 31.9% Control: 28.8%

• Estimated that 21-61% of patients seeking weight loss treatment meet the criteria for ADHD

After participating in a 16-week behavioral weight loss program, participants with ADHD: Lost significantly less weight Were less likely to lose more than 5% of body weight Consumed fast food more frequently Were more likely to eat in response to negative

moods Reported more frequent weight loss attempts and

greater difficulty with weight loss skills like tracking calories, keeping food records and meal planning May be necessary to give extra instruction and support

with these skills

Counseling Techniques Techniques associated with cognitive

behavioral therapy may be useful regardless of whether weight loss is a goal Role playing and modeling

May help a child or adult with ADHD practice more acceptable behaviors involving food Meal planning, shopping and organization

Delay and distraction May help in learning to manage impulsivity

Sample Menu Breakfast

1 cup sliced strawberries ½ cup skim milk 1 cup multigrain Cheerios

Morning Snack ¾ cup sliced carrots 3 tablespoons hummus

Lunch 3 ½ oz. hamburger patty (95% lean) with 1 oz. cheddar cheese, 1 thick slice of tomato and 1

whole wheat hamburger bun 1 ½ cups mixed greens with ½ cup sliced cucumber, 1 ½ tablespoons flaxseed oil and 1

tablespoon red wine vinegar Afternoon snack

1 medium apple 1 fat free string cheese

Dinner 4 oz. skinless salmon (broiled) with 2 tablespoons hollandaise sauce 1 cup brown rice 1 cup broccoli with cheese sauce 1 whole wheat dinner roll

Evening snack 1 fat free Greek yogurt 1 graham cracker (2 squares)*Choose brands free of artificial colors/flavors/preservatives

Total calories: 1,980 Linoleic Acid: 10 g

EPA: 595mg DHA: 843mg Iron: 30mg Zinc: 30mg

Sodium: 2433mg Saturated fat: 24g