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Categories: 2012, June
by Marianne Glanzman, MD
RECENTLY, THERE HAS BEEN RENEWED
INTEREST in the question of whether dietary interventions can
be useful for children with ADHD. This article is not intended to be a
review of the relative merits of different approaches, but rather a
roadmap for how to implement approaches for which there is some positive
evidence, safely and effectively. ADHD is not caused by your
child’s diet, but increasing evidence suggests that some symptoms,
particularly mood and self-control, may be affected by what she or he
Eating and nutrition in children
The US Department of Agriculture provides Dietary Guidelines for
Americans about every five years. In 2005, the familiar Food Guide
Pyramid, showing the recommended number of servings per day for each
food group, was modified and replaced by the first of two icons.
MyPyramid showed portion sizes in cups and ounces instead of number of
servings, with tables of specific recommendations for different age
groups. MyPyramid was replaced by MyPlate in June 2011.
MyPlate is a simple guide showing that for each meal, one-half of the
plate should consist of fruits and vegetables, one-quarter of protein,
and one-quarter of carbohydrates, along with a serving of dairy or
calcium-rich substitute. Highlights include:
Emphasis is placed on vegetables,
fruit, whole grains, and low-fat dairy products.
At least half of grain intake should come from whole,
not processed, grains.
Daily protein should come from a variety of lean meats
and poultry, fish, cooked dry beans, eggs and nuts.
Some oil is important for health, and should ideally
come from fish, nuts, and liquid oils.
Saturated and trans fats, cholesterol, salt and added
sugars should be minimized.
The Food and Nutrition Board establishes the recommended daily allowance
(RDA) for each nutrient for each age group. The RDA is the amount of a
given nutrient that meets the needs of over ninety-seven percent of the
population. Some nutrients do not have an RDA because insufficient
information is available. RDAs are shown on labels of supplements and
supplemented foods. Will eating according to these guidelines help ADHD?
A recent study in teens suggests that a "Western" diet—high in
total fat, saturated fat, refined sugars, and sodium—is associated
with double the likelihood of a person’s having ADHD compared with
eating a "healthy" diet, higher in omega-3 fatty acids, fiber, and
folate and low in total fat, saturated fat, and refined sugars. This
study certainly doesn’t prove that the Western diet "causes" ADHD,
but in the meantime, aiming to follow the guidelines is an important
goal for health in general. Let’s look at some specifics.
Protein and carbohydrates
Protein, made from chains of amino acids, comes from meats, fish,
eggs, dairy, beans, nuts and seeds. Proteins are structural components
of cells and catalysts (enzymes) for the chemical reactions. Amino acids
are also precursors for the synthesis of neurotransmitters, the
chemicals brain cells use to communicate. Starches and sugars are
carbohydrates, our main energy source. Glucose, the simplest sugar, is
essentially the only energy source for the brain.
Children who eat a substantial breakfast spend more time on task later
in the morning than those who eat minimal or no breakfast. The inclusion
of protein with carbohydrate is best for sustained cognitive performance
over several hours. Studies looking at the effects of sugar in a meal or
in the diet in the short term show little effect on cognitive
performance or behavior in children with or without ADHD. A sugar drink
can actually improve attention, memory, reaction time and mood, but
these tend to be short-term effects when glucose levels are rising.
The best overall cognitive effects throughout the morning are achieved
with a protein-rich or balanced protein-carbohydrate breakfast. A
high-carbohydrate breakfast, especially one consisting of high-glycemic
carbohydrates (sweets and refined, rather than whole grains which break
down into glucose quickly) is more likely to be followed by a rapid rise
and then a rapid fall in glucose level. A rapid fall in glucose level
can be associated with adverse symptoms. Over the long term, repeated
high-carbohydrate meals can lead to poor glucose utilization (the
ability to get glucose into the cells where it is needed), which is
associated with poorer performance on a variety of cognitive tasks.
So, how much protein is enough? There isn’t a clear answer. In
general, the RDA for protein in children is about forty grams per day,
which can be divided into about ten grams per meal and five grams in
each of two snacks. There is roughly seven grams of protein in a cup of
yogurt, a hot dog, or an egg.
To see if more protein would be helpful, try the following experiment.
When your child has an even number of days off from school in a row,
alternate a high-protein, low-carbohydrate breakfast one morning (such
as eggs, meat, cheese, milk; no juice or fruit) with a
high-carbohydrate, low-protein meal the next (pancakes or waffles,
syrup, juice; no milk or meat). Give your child some tasks to do that
require attention, effort, and self-control later in the morning so you
are more likely to be able to tell if there is a difference.
If you see an improvement with the high-protein breakfast, it does not
mean that your child must only eat protein for breakfast; some
carbohydrate is best for immediate energy. A high-protein meal, if
helpful, is meant for breakfast only; go back to MyPlate recommendations
for other meals and snacks.
Vitamins and minerals
Vitamins and minerals facilitate chemical reactions throughout the
brain and body. Several individual nutrients have been associated with
ADHD. These include iron, zinc, magnesium, and polyunsaturated fatty
acids. Reports of supplementation with these nutrients or multi-nutrient
products suggest that cognitive, mood, and antisocial behavior symptoms
may be improved with supplementation, but this seems to be true
primarily for individuals who are deficient to start with.
It can be difficult to assess nutritional adequacy because we
don’t absorb all of the nutrients we ingest, and, while functional
levels of some nutrients can be reliably measured (such as ferritin
level to check for iron stores), for others, it is not certain that
blood or blood cell levels accurately reflect tissue levels. If your
child eats a varied, balanced diet, a broad spectrum
multivitamin-multimineral supplement containing less than fifty percent
of the RDA may make sense because it is very difficult for children to
eat enough food to consistently supply one hundred percent of
the RDA. For a child with a poor diet, more may be needed, but it would
be wise to consult a nutritionist in this situation.
A "typical" multivitamin-multimineral supplement will include vitamins
A, B1 (thiamine), B2 (niancin), B3 (riboflavin), B5 (pantothenic acid),
B6 (pyridoxine), B12 (cyanocobalamin), C, D, E and zinc, calcium,
magnesium, copper, and manganese. Some will include additional nutrients
such as biotin, vitamin K, iodine, selenium, trace minerals, choline,
inositol, and antioxidants. Fortified breads and breakfast cereals are
importance sources of vitamins and minerals for many children. Calcium
and magnesium are utilized in a 2:1 ratio in the teeth, bones, and
nerves. Children who consume the recommended servings of dairy products
may be getting sufficient calcium, but relatively less magnesium, and
multivitamin-multimineral supplements don’t usually contain much
magnesium. You may need to add some, but not more than twenty-five
percent of the RDA.
Minerals and fat-soluble vitamins (A, E, D, K) can accumulate in the
body if taken in excess over the long term, with potential negative
consequences. Megadoses (several times the RDA) of single or combined
nutrients should not be used. They can adversely affect the nervous
system or liver, as well as compete with other nutrients for absorption.
Since supplements aren’t regulated, it is best to purchase from a
company that reports independent testing for quality control. Before
using supplements, check with your doctor to insure that they
don’t contain anything that may interact with medications, and
bring all of your supplements when you visit the doctor.
Omega-3s and omega-6s: polyunsaturated fatty acids (PUFAs)
Fatty acids are structural components of brain cell membranes and
precursors for cell-to-cell communication molecules in the brain,
immune, and endocrine systems. They have a carbon "backbone" that is
from eleven to twenty-seven carbon molecules long. "Polyunsaturated"
means they contain several double bonds.
The carbon location of the first double bond determines the name
omega-3, 5, 6, 7, or 9. Shorter carbon chains are elongated by enzymes
that require zinc as a cofactor. Because the same enzymes are used to
elongate fatty acids in each number group, an excess in one can limit
elongation of others. The 18-carbon omega-6, linoleic acid and the
18-carbon omega-3, linolenic acid are considered "essential" fatty acids
because they can’t be made by the body; they must be ingested.
From these, the longer carbon chain fatty acids are synthesized.
Omega-3s are found in algae, seeds (flax, hemp, sunflower, and chia),
walnuts, leafy greens, and fatty fish such as salmon. Omega-6s
(particularly arachidonic acid) are found in meat, dairy, eggs, and
several vegetable oils. A dietary ratio of 4:1 (omega-6 to omega-3) is
ideal, but the standard "Western" diet is closer to 20:1, so it is
presumed that many individuals are relatively omega-3 deficient.
The omega-3’s DHA (docosahexaenoic acid) and EPA (eicosapentaenoic
acid), and the omega-6 GLA (gamma-linoleic acid) are most important for
brain function. Children with ADHD have lower levels of these compared
with children without ADHD. Studies using single supplements (either an
omega-6 or DHA alone) have not shown positive treatment effects on ADHD
symptoms, but studies using a combination of DHA, EPA, and GLA with a
predominance of EPA have shown somewhat more promising results. Fish oil
is the primary source of EPA and DHA together, and evening primrose or
borage oil are sources of GLA.
Although RDAs for omega-3s do not yet exist, the Food and Nutrition
Board determined Recommended Adequate Intakes for total omega-3 fatty
acids in 2002. These range from 700–1600 mgs per day in children
and teens. This should be given with about 50 mg of GLA. It takes about
three to four months in order to replete deficient levels in cell
membranes, so effects are not seen quickly, are likely to be subtle, and
may be more prominent for mood or anxiety than core ADHD symptoms.
Though generally felt to be safe, PUFAs, like any supplement, should be
treated like a medication, with monitoring of positive and negative
effects, and without other simultaneous changes. I am aware of one young
child who became aggressive after starting an omega-3 supplement, and
was later found to have relatively high omega-3 levels and relatively
low omega-6 levels. There are also anecdotal reports of behavioral
deterioration in children taking 4000-5000 mg per day over several
years. Red blood cell fatty acid levels are becoming easier to obtain
and may help to guide treatment. If using fish oil, it is important to
use a brand that reports independent testing to document the absence of
mercury and other toxins.
There are two broad elimination strategies: the Feingold Program
(elimination of artificial colors, flavors, certain preservatives, and
salicylates) and elimination of specific foods.
To test the Feingold Program, all artificial colors, all artificial
flavors, the preservatives BHT (butylated hydroxytoluene), BHA
(butylated hydroxyanisole), and TBHQ (tertiary butylhydroxyquinone),
aspirin and other non-steroidal anti-inflammatory medications, synthetic
sweeteners, and naturally occurring salicylates are entirely eliminated
from the diet for six weeks. Naturally occurring salicylates include
oranges, tangerines, clementines, apples, grapes, raisins, berries,
cherries, peaches, nectarines, apricots, plums, prunes, currants,
tomatoes, cucumbers, chili and bell peppers, pickles, almonds, oil of
wintergreen, birch, cloves, rose hips, chili powder, paprika, cider and
cider vinegar, coffee, and tea. Allowed fruits include all melons,
pineapple, banana, grapefruit, lemons, limes, all tropical fruits, such
as mangoes, papaya, guava, and passionfruit. All other vegetables, nuts,
spices, seeds, oils, and all meats, dairy products and grains without
eliminated additives are allowed.
If an improvement is seen, the naturally-occurring salicylate foods are
added back one at a time to see which, if any, provoke re-occurrence of
symptoms. If an improvement is not seen, guidance through the Feingold
Association can be provided about other food additives, inhaled
additives, or foods that may be contributing. An adequate trial requires use of the materials from the
Feingold Association that delineate acceptable and non-acceptable
prepared products, since some of the eliminated items do not need to be
listed on labels, and even a small amount can provoke a reaction.
Parents of children who respond typically report improvements in
adaptability/flexibility, mood, and quality of sleep, and bedwetting or
other physical symptoms in addition to core ADHD symptoms. Although the
additives and salicylates eliminated on the Feingold Program are widely
believed to affect only a small percentage of children, studies are
commonly flawed in several ways that would minimize positive results.
For example, one flaw is that the majority of studies evaluate the
effects of dyes alone. (A British version eliminates dyes and sodium
benzoate). The Feingold Program is most likely to be useful in
preschoolers with sleep, irritability/mood issues, and allergic or other
symptoms because they are both most likely to respond and most difficult
to medicate without adverse effects.
The oligoantigenic (or "few foods") diet has been used to identify
children whose neurobehavioral symptoms might be triggered by specific
foods. For up to two weeks, only a limited number of low-allergen foods
are allowed (for example: two meats, two starches, two fruits, certain
green vegetables, oil, and vitamin/calcium supplements). If improvements
are seen, foods are reintroduced singly to identify those which
triggered behavior deterioration.
In one study, offending foods were eliminated again, and the subject was
challenged in a blinded fashion with either a placebo or the disguised
suspect food. Behavior deteriorations occurred more often with the food
than placebo challenge. All children who reacted to foods reacted to
more than one, and all who reacted to foods also reacted to tartrazine
(yellow #5) and sodium benzoate (a preservative). The most common
offending foods identified in twenty percent or more of subjects were
(in decreasing order) tartrazine/benzoate, soy, cow milk, chocolate,
grapes, wheat, oranges, cheese, eggs, peanuts, corn, fish, oats, melons,
tomatoes, and ham/bacon. Interestingly, these are predominantly the
foods that cause most classic food allergies (dairy, wheat, soy, eggs,
nuts, fish) or Feingold’s high-salicylate foods (grapes, oranges,
Unfortunately, there is no test to identify foods that might cause
behavior symptoms short of an oligoantigenic diet trial, although it may
not need to be as extreme as the form used in research. The top
offenders listed above may be sufficient. Neither the type of
immediate-reaction IgE allergy tests typically done in the
allergist’s office nor IgG-mediated ELISA blood tests can reliably
identify provoking foods.
When your child won’t eat a healthy diet
If your child has a very limited diet, if you are considering
supplementing with more than fifty percent of the RDA of several
nutrients, if you are using an oligoantigenic diet, or if you have any
other concerns about your child’s nutritional intake, it is best
to seek the advice of a nutrition professional, either a nutritionist or
nutritionally knowledgeable physician. A careful diet history can be
analyzed to determine deficiencies or excesses.
If your child also has gastrointestinal symptoms, such as gagging,
difficulty swallowing, persistent reflux or vomiting, loose stools or
constipation, abdominal pain, or blood in the stool, or if he or she is
not gaining weight or growing as expected, a pediatric
gastroenterologist should be consulted for a thorough evaluation. An
evaluation may reveal a structural, mechanical, infectious,
inflammatory, metabolic, or allergic cause for poor movement of food
through the GI tract or poor digestion. Children sometimes show limited
food choices as their most obvious symptom of one of these
A speech or occupational therapist with feeding expertise can determine
whether the skills for chewing and the oral sensory motor system are
intact. If not, treatment may help; however, this does not preclude an
underlying medical condition.
When the presence of a medical condition has been eliminated, a
structured, repeated exposure plan using positive reinforcement can help
to introduce new foods into the diet. This kind of feeding behavior
management is best done during the summer without the added stress of
school, and with the assistance of a psychologist or other clinician
with expertise in this area.
Sometimes, nutritional or diet changes can be part of a comprehensive
treatment plan to help your child with ADHD experience success. As with
other interventions, a clinician who will help you evaluate the positive
and negative effects is an invaluable ally.
DIETARY REFERENCE INTAKES (RDAS)
THE FEINGOLD ASSOCIATION
Glanzman, M. (2009) ADHD and Nutritional Supplements. Current
Attention Disorder Reports, 1:75-81.
Hurt, E.A., Arnold, L.E., Lofthouse,N. (2011). Dietary and Nutritional
Treatments for Attention-Deficit / Hyperactivity Disorder: Current
Research Support and Recommendations for Practitioners. Current
Psychiatry Reports, 13:323-332.
Stevens, L.J., Kuczek, T., Burgess, J.R., et al. (2011). Dietary
Sensitivities and ADHD Symptoms: Thirty-five Years of Research.
Clinical Pediatrics, 50(4) 279-293.
Transler,C., Eilander, A., Mitchell,S. et al. (2010). The Impact of
Polyunsaturated Fatty Acids in Reducing Childhood Attention Deficit and
Hyperactivity Disorders. Journal of Attention Disorders, 14(3)
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