December 2007

Hyper Holidays and Hyper Kids: A Dietary Solution?
By Carol Ann Brannon, MS, RD, LD
Today’s Dietitian
Vol. 9 No. 12 P. 12

CDR Learning Codes: 4090, 4150, 5070, 5110, 5320; Level 2

‘Tis the season to be … distracted!

Parties, family gatherings, and special school programs cram our schedules; everyone feels hassled and stressed. And the media—don’t get me started on the media.

Children feel the pressure, too. The holidays can escalate sibling rivalry and increase feelings of estrangement and isolation from peers. Carefully established schedules are shattered, and there’s more to do in less time. As the big day approaches, families are physically, emotionally, and mentally exhausted. Then they sit down to eat…

For children with attention-deficit/hyperactivity disorder (ADHD), the holiday season is even more overwhelming and chaotic as external stimuli mount, expectations soar, and parents’ time is rationed. Parents say children with ADHD experience intensified symptoms around the holidays, increased hyperactivity, and deteriorated social interactions. And food choices proliferate, sometimes in an unhealthy way.

Many parents and health professionals seek nutrition and diet alternatives to drug therapy to manage ADHD. This article will help nutrition professionals understand the state and direction of research into nutritional strategies for ADHD and related disorders.

Definition, Etiology, and Diagnosis
ADHD has been researched for more than 40 years, making it the most studied childhood psychiatric disorder. According to the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association, ADHD is a neurobiological disorder characterized by hyperactivity, impulsiveness, and inattention or the inability to sustain attention or concentration in developmentally appropriate ways.1,2 ADHD is often referred to as ADD/ADHD because it is classified into two categories: poor sustained attention and hyperactivity-impulsiveness. There are three subcategories: predominantly inattentive, predominantly hyperactive-impulsive, and combined types.1-3

Children with only ADD are less fidgety and energetic but are more likely to daydream and not complete schoolwork. Children with ADHD act out, disrupt, and overreact.

While most children occasionally demonstrate some ADHD behaviors, children diagnosed with ADHD consistently and more intensely demonstrate symptoms. As children grow, develop, mature, and change, so do their ADHD symptoms. With maturity and behavior modification, children with ADHD can learn to manage their symptoms without medication or with a reduced dose. Many children do not outgrow ADHD, and adults can also have ADHD, although they usually learn how to manage their symptoms and may continue to take prescription medications.1,3

Statistical estimates of the number of children affected by ADHD vary from study to study. The National Institutes of Health (NIH) estimates that between 3% and 5% of school-aged children (approximately 1.5 to 2.5 million children) are affected, while other studies report a greater than 10% incidence.1 One recent survey estimated that 8.7% of U.S. children aged 8 to 15 meet the ADHD diagnostic criteria, but less than one half of them receive treatment.4

The incidence of ADHD is higher in some population groups. School-aged boys with ADHD outnumber girls by a margin of between two and three to one. ADHD also occurs more frequently in children of low socioeconomic status. Researchers speculate that ADHD is higher in these children due to the elevated prevalence of ADHD risk factors, such as premature birth and/or in utero or childhood exposures to toxic substances. Despite the higher prevalence, one study showed that children of lower socioeconomic status were least likely to consistently receive or take medications.4

The etiology of ADHD remains a mystery, but researchers have identified several theories and contributing factors. There appear to be differences in the brain structures and disturbances in certain brain neurotransmitter activity in children with ADHD, which can be detected using brain imaging. Genetics and environment also play roles in ADHD development. If one sibling has ADHD, the chance of another sibling having ADHD is increased. Exposure to environmental toxins such as pesticides, lead, alcohol, and cigarette smoking has been implicated. Studies have confirmed that some, but not all, children experience sensitivities to food additives and colorings or have food allergies that negatively influence their behavior and attentiveness.1,5,6

Despite advances in research, ADHD remains elusive and difficult to diagnose since there is no specific or definitive diagnostic test. Thus, despite the possibility of structural or functional brain abnormalities, diagnosis is typically based on behavioral assessment tests, observations from parents and teachers, and clinical assessments by healthcare providers.1 Because of this subjectivity, controversy about diagnosing ADHD, particularly overprescribing psychoactive drugs to young children based on subjective diagnosis, has raged. Nevertheless, drug therapy dominates ADHD treatment.

Pharmacotherapy for ADHD
American children with ADHD are commonly treated with central nervous system stimulants, usually methylphenidate (Ritalin and longer-acting forms such as Concerta, Focalin, Metadate, and Methylin) or amphetamines (Adderall and Dexedrine). Although ADHD prescription medications have an approximate effectiveness rate of 75% and are fast-acting, they are not without risks or side effects (see Table 1).7

Because of side effects and concerns about the long-term consequences of using psychoactive drugs during developmental years, parents have searched for alternatives. Traditional Western medicine focuses on managing symptoms, and ADHD medications do not address the possible underlying causes. In contrast, Eastern philosophy focuses on treating the underlying causes of a condition and uses “food as medicine.”

More American parents are adopting an Eastern philosophy, recognizing their child’s “biological individuality” and seeking to treat ADHD through nutrition and other natural therapies. Nontraditional approaches include nutrition therapy and supplementation, aromatherapy, biofeedback, Chinese medicine, Cranialsacral therapy, homeopathy, hypnotherapy, and massage therapy.1,5 The discussion of many of these, including herbal therapy, is beyond the scope of this article.

Since parents and practitioners have sought other ways to understand and treat ADHD, early on, diet came into focus.

Diet Connection
A firestorm of controversy erupted in the early 1970s when Benjamin Feingold, MD, then chief emeritus of the department of allergy at the Kaiser Foundation Hospital and Permanente Medical Group in San Francisco, reported that 30% to 50% of his hyperactive patients benefited from a diet free of artificial food colorings and additives and naturally occurring salicylates (see Table 2). The Feingold Diet stressed elimination of these substances.5

While many parents eagerly embraced the diet, Feingold’s findings were met with skepticism and criticism from many child behavior experts, pediatricians, and the processed food industry. Dietitians noted the restrictions on many common fruits with dismay. Despite the skeptical criticism, in 1975 a U.S. Department of Health, Education, and Welfare committee concluded that “the evidence taken as a whole is sufficient to merit further investigation into the relationship of diet and hyperkinetic syndrome.”5,8

In 1982, the NIH convened a conference to review the early scientific research and advise health professionals and the public regarding diet and ADHD. Their conclusion was that controlled studies “did indicate a limited positive association between … [Feingold-type] diets and a decrease in hyperactivity.” The panel recommended further broad research on the diet-behavior connection.5,9 Despite the recommendation for further research, only a limited number of controlled studies have been conducted in the past 30 years.

A 1999 Center for Science in the Public Interest (CSPI) review of 17 controlled studies—most focused on artificial colors while some examined the effect of allergens such as milk and corn—found that diet did adversely affect some children’s behavior, sometimes dramatically. The percentage of children that responded to diet intervention varied widely among the studies, as did the magnitude of the effect. Only six reviewed studies determined that there was no dietary effect on behavior.5

A recent randomized, double-blind, placebo-controlled, crossover trial involving 153 children aged 3 and 144 children aged 8 or 9 in the United Kingdom found that dietary intake of artificial food colorings and additives, particularly sodium benzoate, resulted in an increase in hyperactivity.10

A lack of consensus continues regarding the percentage of children who respond to dietary therapy, to what degree they respond, which subgroup of children is most likely to respond, sensitivities to artificial food additives and foods, and how to implement diet therapy.5 There is a wealth of anecdotal evidence citing improvement in ADHD symptoms, including sleep problems and mood changes, secondary to diet therapy. Preschool children and children affected by eczema, asthma, allergies, hives, and hay fever appear to be more responsive to dietary interventions.11

Today, several theories and approaches exist. A combination of these nutritional interventions may be implemented (see Table 3).1,11-13

Carbohydrate-selective Diets
Some children have responded favorably to a diet free of sugar, relatively low in simple carbohydrates, moderate in complex carbohydrates, and relatively high in protein. The reported benefits are primarily anecdotal, but there are reports that a carbohydrate-selective diet has a calming effect and improves learning.13 Nonetheless, in comparison to aspartame-sweetened foods, intake of high-sugar foods did not aggravate hyperkinesis.13 Generally, it has been shown that children with ADHD do not have a higher intake of sugar than children without ADHD, and simply giving sugar or sweets has also failed to aggravate hyperkinesis compared with the control, aspartame-sweetened foods.13

The inconsistent scientific findings may be due in part to poor study design and shortcomings in methodologies. They may assess only sucrose intake and lack data on other sugars, evaluate only acute or short-term effects, and may not account for food coloring and other additives that may produce a synergistic effect on behavior. Short-term studies may fail to detect the benefits from long-term and sustained dietary changes.13

Regardless of these questions, it is well-established that diets high in sugar and refined carbohydrates are also often lacking in nutrient density, vitamins and minerals, and dietary fiber. Parents and teachers continue to believe that high sugar intake does negatively influence a child’s behavior.1,13

In addition, a high-sugar diet for some children may aggravate or trigger disturbances in blood sugar control, disrupt the homeostasis of bowel flora, and promote or favor inflammation. Hyperinsulinism and corresponding hypoglycemia may be a factor in aggressive and irritable behavior observed in children with ADHD. It may be helpful to screen for dysinsulinism by administering a glucose/insulin tolerance test, especially for children with a family history of glucose intolerance and/or diabetes.

Reduction/Elimination Diets
The prevalence, diagnosis, and treatment of immunoglobulin E (IgE)-mediated food allergies in children is widely acknowledged and well established. Many children with ADHD also have food allergies and receive conventional allergy treatment (allergy shots). Do food allergies cause or trigger ADHD behavior? More research regarding the possible connection between IgE food allergies and ADHD behavior is needed for clarification. Nutrition therapy focuses on the elimination or removal of the identified allergens (see Table 4). Medical management may involve allergy injections or antigen dilutions (specially prepared dilutions containing food antigen administered as sublingual drops on a set schedule).11-13

Unlike food allergies, there is great debate over the clinical definition, diagnosis, and legitimacy of food sensitivities or delayed hypersensitivities. Food sensitivities are generally thought to be delayed immunoglobulin G (IgG)-mediated reactions, in contrast to IgE-mediated reactions, which occur immediately on ingestion of a food antigen. Several strategies for assessing food sensitivities are currently utilized in complementary medical practices, but many traditional healthcare practitioners do not acknowledge IgG reactions or testing. Two commonly used approaches are serum IgE and IgG testing (enzyme-linked immunosorbant assay, or ELISA) and institution of an elimination diet, followed by reintroduction of suspected foods.

Many parents are experimenting with the gluten-fee and casein-free diet (GFCF) and reporting behavior and cognitive improvements in their children with ADHD. There is little research supporting or recommending a GFCF diet for ADHD, but there is an increasing amount of anecdotal evidence.11,12,14

Pesticides
The Clean Water Fund and Greater Boston Physicians for Social Responsibility released “In Harm’s Way: Toxic Threats to Child Development,” a report citing that more than 80% of adults and 90% of U.S. children have pesticide residue in their bodies.15 One study found a link between chlorpyrifos (an organophosphate insecticide used on corn, wheat, and numerous fruits and vegetables) and learning delays, reduced physical coordination, and behavior problems, particularly ADHD.

A recent study conducted on mice found that organophosphate exposure inhibited the activity of a large gene called neuropathy target esterase (NTE). This gene is active in the hippocampus, cerebellum, and spinal cord, all parts of the brain that control movement. This inhibition either killed the mice before birth or over time led to a range of behaviors very similar to ADHD. The effect of pesticides and insecticides on ADHD, obesity, and diabetes is currently under investigation.4,6

Thus, selecting organic foods, especially produce, may be worth the extra expense.

Heavy Metal Detoxification
Lead toxicity is another factor associated with hyperactivity. “In Harm’s Way” also found that the blood levels of lead in at least 1 million U.S. children have now reached a level that could affect behavior and cognition.15 In addition, a few studies report that children with ADHD have greater retention of aluminum and cadmium.13

Historically, chelation treatment has been limited to acute or severe metal poisoning. However, chelation therapy is gaining wider attention, especially for children with autism. Chelation therapy can be risky and is considered controversial by many. It should be administered by a trained and experienced physician. Some supplement companies have begun offering products with “natural chelating agents,” including chlorella (blue-green algae), alpha-lipoic acid, selenium (preferably yeast-based), and vitamin C. Foods purported to have chelating properties include garlic, cilantro, whey protein, and sea vegetables. Extreme caution should be exercised regarding chelating agents and therapy, as this area remains controversial and many products are suspect.11-13

Restoring Gut Health
The intestines are habitat to millions of microorganisms, including probiotics (beneficial bacteria) and pathogenic or disease-promoting bacteria. There is substantial scientific evidence to support the health benefits and therapeutic properties of probiotics. Pathogenic bacteria produce endotoxins that have toxic effects. Certain endotoxins have been identified in the urine of children with ADHD, autism, and other psychiatric disorders.11,12

A thriving population of colonic probiotics prevents the overgrowth of pathogenic bacteria, enhances immunity, and protects against allergies. Probiotics can protect against the intestinal overgrowth of Candida yeast, which can damage the brush-border lining of the intestine. Damage to the intestinal lining can result in the leakage of dietary peptides and food antigens into the bloodstream. This condition is known as intestinal permeability or leaky gut syndrome. Thus, probiotic therapy may be beneficial for some children with ADHD, especially those with asthma, food allergies, eczema, hives, hay fever, or yeast infections.11,12

Nutritional Supplementation
The concept of “biological individuality” suggests that children with ADHD may have unique and genetically determined biological requirements. Studies indicate that children with ADHD are more likely to be deficient in vitamin B6, magnesium, zinc, and omega-3 fatty acids (docosahexaenoic acid [DHA]) than children without ADHD.

The use and recommendation of dietary supplements for ADHD is controversial. However, given that many children do not receive adequate nutrition through their diet, taking a daily multivitamin/mineral supplement may be warranted.11-13

Nutrient deficiencies occur in stages. An accurate nutrient assessment requires laboratory assays, including serum vitamins, red blood cell minerals, serum iron, plasma essential fatty acids (EFA), plasma and urinary amino acids, and urinary organic acids. A child may have a preliminary nutrient deficiency with no obvious behavioral symptoms. Likewise, a child may have a subclinical deficiency, but the accompanying behavioral symptoms, such as irritability, may not be associated with a nutrient deficiency.16-18

One class of nutrients is known to be associated with cognitive functions. Lipids, which comprise 60% of the dry weight of brain matter, are important for optimal cognitive development, ability, and performance. Linoleic acid (LA; 18:2n-6) and alpha-linolenic acid (ALA; 18:3n-3) are EFAs and must be consumed in the diet because they cannot be synthesized in the body. EFAs are converted to a variety of longer, more highly polyunsaturated products that maintain cell membrane structure and integrity. Also, EFAs are the precursors for eicosanoids, localized hormones involved in nearly every biologically significant process in the body.

DHA and eicosapentaenoic acid (EPA) are not classified as EFAs but are nonetheless critically important. ALA is converted to EPA and DHA in the body. However, this conversion is somewhat inefficient in terms of providing DHA and EPA directly to cells. DHA (derived from ALA and found in fish oil) is one of the most plentiful and highly concentrated fatty acids in certain brain regions and the retina of the eye. Depletion of DHA from these regions may compromise sensory and brain function.17-19

Some ADHD symptoms are similar to EFA deficiency symptoms. A clinical deficiency of omega-6 fatty acids leads to impaired growth, dry and scaly skin, polydipsia, and polyuria, among other symptoms. Deficiency of omega-3 fatty acids in rats and monkeys is associated with behavioral, sensory, and neurological dysfunction. Many children with ADHD are also affected by eczema, allergies, and asthma, conditions that can benefit from supplementation with the omega-3 fatty acids DHA and EPA.11,12

Studies indicate that children with ADHD have significantly lower plasma concentrations of the omega-3 fatty acids, particularly DHA.1,17 One analysis study found an inverse relation between total plasma omega-3 fatty acid proportions and both behavioral assessment scores (Conners’ Parent Rating Scale) and teacher scores of academic abilities.19 An inverse relationship was not found between omega-6 fatty acids and behavioral assessment scores. Burgess et al report that subjects deficient in omega-3 fatty acids had significantly more behavioral problems (eg, temper tantrums), health problems, and sleep problems than children who were not deficient.18

Several theories attempt to explain the lower omega-3 fatty acid plasma levels in children with ADHD. One theory is that children with ADHD may be unable to normally metabolize LA, resulting in low levels of DHA and EPA. Children with ADHD may not be able to properly absorb EFA from the gut or metabolize it. Another theory is that children with ADHD have higher EFA requirements.17-19

Given the reality that most children do not like fish and their ingestion of fresh fish must be limited due to the risk of pollutants and mercury, fish oil supplements may be warranted. However, fish oil supplements should be used only under a physician’s supervision. A variety of fish oil supplements are available for and marketed to children. Advances in biotechnology have resulted in fish oil (DHA/EPA) supplements that do not have a fishy taste or smell, as well as the development of vegan DHA/EPA supplements derived from sea algae. The World Health Organization recommends 800 to 1,100 milligrams of ALA and 300 to 500 milligrams of DHA + EPA per day for children.20

What Now?
As the previous studies indicate, research into nutrition and dietary interventions for ADHD is in its infancy. There is still no clear consensus on defining the condition despite the DSM-IV diagnostic criteria, and arguments abound about the ethics of identifying high-energy children as psychologically impaired, particularly when the next step is often giving them psychoactive drugs. Until there is a reliable consensus, any nutrition therapy will have to prove itself patient by patient, family by family. There appears to be no reliable predictor of the efficacy of nutrition therapy for all children with ADD or ADHD, but there is a growing body of anecdotal evidence.

However, we do know that foods marketed to children are typically low in fiber and high in sugar and unhealthy fats. Many contain suspect preservatives, coloring agents, and other additives. We can say with confidence that all children can benefit from a well-balanced, whole-food, plant-based diet.

A multifactorial disorder such as ADHD requires a team approach. Practitioners should have a solid understanding of nutritional principles, diagnostic screening, environmental interactions, and stimulant and antidepressant medications, as well as a willingness to be creative and think outside the box. As we’ve seen, diet can be a part of the plan.

From a practical standpoint, nutrition therapy is worth trying for a three-month period. Dietary changes are certainly safer and cheaper than stimulant drugs. Needless to say, controlling the diets of young children can be difficult, especially during the holidays. An increasing number of books and cookbooks are available for families with children affected by ADHD, autism, and food allergies.11,12,14

Parents are the gatekeepers for food prepared and served in the home and can advocate for improvements in school-provided meals. Dietitians can play an important role by educating, encouraging, and empowering parents to become mindful gatekeepers—and get through the holidays.

— Carol Ann Brannon, MS, RD, LD, is a consulting dietitian at Fowler YMCA and in private practice in Georgia.

References
1. Lombardi RM. ADHD: A modern malady. Nutrition Science News. August 2000.

2. American Psychiatric Association Online Web site. Available here.

3. Breakey J. The role of diet and behaviour in childhood. J Paediatr Child Health. 1997;33(3):190-194.

4. Froehlich TE, Lamphear BP, Epstein JN, et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US Children. Arch Pediatr Adolesc Med. 2007;161(9):857-864.

5. Jacobson MF, Schardt D. Diet, ADHD, and Behavior: A Quarter-Century Review. Center for Science in the Public Interest. Washington, DC: 1999.

6. Beyond Pesticides/National Coalition Against the Misuse of Pesticides. Persistent pesticides linked to ADHD, obesity, and diabetes. School Pesticide Monitor. 2007;7(1):1-2.

7. Swanson JM, McBurnett K, Wigal T, et al. Effect of stimulant medication on children with attention deficit disorder: A ‘review of reviews.’ Except Child. 1993;60:154–162.

8. Interagency Collaborative Group on Hyperkinesis. First report of the preliminary findings and recommendation of the Interagency Collaborative Group on Hyperkinesis. Submitted to the assistant secretary for health, USDHEW, 1975.

9. Defined diets and childhood hyperactivity. NIH Consensus Statement. 1982;4(3):1-11.

10. McCann D, Barrett A, Cooper A, et al. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: A randomised, double-blinded, placebo-controlled trial. Lancet. 2007; 370(9598):1560-1567.

11. Bock K, Stauth C. Healing the New Childhood Epidemics Autism, ADHD, Asthma, and Allergies: The Groundbreaking Program for the 4-A Disorders. New York: Random house; 2007.

12. McCandless J. Children With Starving Brains—A Medical Treatment Guide for Autism Spectrum Disorder, 2nd ed., Putney, Vt.: Bramble Books; 2003.

13. Dye J. Nutritional & dietary treatments for ADHD: Nutritional and Dietary Therapies. Available here. Accessed September 30, 2007.

14. Compart P, Laake D. The Kid-Friendly ADHD and Autism Cookbook The Ultimate Guide to the Gluten-Free, Casein-Free Diet. Beverly, Mass.: Fair Winds Press; 2006.

15.The Clean Water Fund and Greater Boston Physicians for Social Responsibility. In Harm’s Way: Toxic Threats to Child Development, Physicians for Social Responsibility. September 2002.

16. Somers E. The Essential Guide to Vitamins and Minerals, 2nd ed., Montreal: Harper Collins; 1995.

17. Colquhoun I, Bunday S. A lack of essential fatty acids as a possible cause of hyperactivity in children. Med Hypotheses. 1981;7(5):673-679.

18. Burgess JR, Stevens L, Zhang W, et al. Long-chain polyunsaturated fatty acids in children with attention-deficit hyperactivity disorder. Am J Clin Nutr. 2000;71(1 suppl):327S-330S.

19. Cheatham CL, Colombo J, Carlson SE. N–3 fatty acids and cognitive and visual acuity development: Methodological and conceptual considerations. Am J Clin Nutr. 2006;83(6 suppl):1458S-1466S.

20. Diet, Nutrition and the Prevention of Chronic Diseases, World Health Organization Study Group on Diet, Nutrition and the Prevention of Non-Communicable Diseases. Geneva, Switzerland: Technical Report Series No. 797. World Health Organization, 1990.

Examination
1. The theories regarding the cause(s) of attention-deficit/hyperactivity disorder (ADHD) include all of the following except:
a. exposure to pesticides and artificial food additives.
b. disturbances in neurotransmitters.
c. differences in brain structure.
d. deficiency of omega-6 fatty acids.
e. genetics playing a role.

2. The side effects of stimulant medications include all of the following except:
a. fluctuating appetite.
b. weight loss.
c. possible decreased growth.
d. increased irritability.
e. daytime sleepiness.

3. The effectiveness of stimulant medications in managing ADHD symptoms appears to be:
a. 95%.
b. 85%.
c. 75%.
d. 65%.
e. 55%.

4. The connection between diet and ADHD symptoms:
a. was first made in the early 1970s by Benjamin Feingold, MD.
b. is controversial.
c. is gaining parental attention and acceptance.
d. considers a child’s biological individuality.
e. all of the above

5. Research supports the findings that:
a. sugar influences and fosters hyperactivity in the majority of children.
b. approximately 85% of children with ADHD are sensitive to artificial food additives and colorings.
c. food sensitivities and allergies may influence the behavior of a subgroup of children with ADHD.
d. children with ADHD are at risk for omega-6 deficiency.
e. all of the above

6. Children with ADHD:
a. are more likely to have asthma and allergies.
b. appear to exhibit unique genetically determined nutritional needs.
c. may have subclinical deficiencies of vitamin B6 and magnesium.
d. exhibit symptoms similar to those of a deficiency of omega-3 fatty acids.
e. all of the above

7. Food sensitivities are:
a. immunoglobulin G-mediated reactions.
b. characterized by delayed hypersensitivity reactions.
c. controversial and not recognized by all conventional healthcare professionals.
d. linked to changes in behavior in some children with ADHD.
e. all of the above

8. ___________ is/are associated with hyperactivity.
a. Low serum iron levels
b. Lead toxicity
c. Protein deficiency
d. High serum docosahexaenoic acid (DHA) levels
e. None of the above

9. Which theory or theories appears to be true regarding essential fatty acids and children with ADHD?
a. They are unable to metabolize linolenic acid normally.
b. They may not be able to properly absorb DHA and eicosapentaenoic acid.
c. They have higher requirements for essential fatty acids.
d. a and b only
e. all of the above

10. Probiotics may be beneficial for:
a. asthma.
b. allergies.
c. eczema.
d. Candida yeast overgrowth.
e. all of the above