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Wednesday, July 2, 2014

Learning and Behavior Series Part 3: Nutrition, Elimination Diets, and Vitamins

This is the third article in a series on Learning and Behavior. It covers some diets that have been recommended for various learning and behavioral benefits, including elimination diets and supplements that might benefit. There will be another part focused on supplements.



Most of us have heard of the claims of cures for all sorts of ills, including behavioral problems (especially ADHD and autism) with simple dietary changes (with and without supplements).

Fears of side effects from long-term medication or a history of medication failures cause families to look for alternative treatment options for child behavior issues. Diet modification and restriction is intriguing for parents since it fits into the ideal of a healthy lifestyle without added medicines and their potential side effects. However, there is a lot of controversy as to whether these restrictions help except in a small subset of children who have true allergy to the substance.

In general if a simple solution through diet was found, everyone would be doing it. That just isn't happening.

I do think that we all benefit from eating real foods -- the ones that look like they did when they were grown, not processed and packaged. Fruits, vegetables, protein sources, whole grains, and complex carbohydrates should be the basis for everyone's diet. It's just good nutrition. But the direct effect of special diets on learning, behavior, and conditions such as ADHD shows limited effects.

Natural does not equal safe. When my kids were young and picky eaters I never would have considered stimulating their appetite with organically grown marijuana. While it is all natural (even organic!) and it might increase their appetites, it would have risks, right? In this case I don't think the risks would outweigh the benefits. But so often parents think that if it's natural, it's healthier than something made by man. Drugs have been tested. They have risks too, but those risks are a known. Some natural therapies have not been as thoroughly tested and they are not regulated, so the label might not correctly identify the contents. For this reason, I think that healthy foods are a great option for everyone, but I hesitate to recommend a lot of supplements, especially by brand.

Over the years there have been many foods or additives that have been blamed for causing learning and behavioral problems. Some of the proposed problematic foods:
  • food dyes
  • refined sugars
  • gluten
  • salicylate and additives
  • dairy products
  • wheat
  • corn
  • yeast
  • soy
  • citrus
  • eggs
  • chocolate
  • nuts
I'm sure the list goes on, but I've got to move on.

Food additives have long been blamed for learning and behavior problems. Back in 1975, Dr. Ben Feingold hypothesized that food additives (artificial flavors and colors, and naturally occurring salicylates) were associated with learning disabilities and hyperactive behavior in some children. Since then many case reports of similar claims have continued to surface, but those do not have the same weight as a double-blinded control study. Most studies done in a scientific manner have failed to show a benefit. There are studies that show improvement in some children who avoid artificial dyes. In my opinion it never hurts to eliminate artificial dyes in your child's diet. If it helps, continue to avoid them. But if no change is noted, don't continue to rely on dye avoidance as a treatment plan.

Another elimination diet that I would not recommend is the GAPS (Gut and Psychology Syndrome) diet, designed by Dr. Natasha Campbell-McBride. She asserts that a wide variety of health problems  (autism, ADHD, schizophrenia, depression, and more) are from an imbalance of gut microbes. Not only has it not been proven to work, I worry that it restricts healthy foods, such as fruits, and kids will develop other problems on this diet. I cannot go into details in this space, but for more information visit Science Based Medicine: GAPS diet.

Gluten is in the news to be the base of many problems. It seems to be a fad to go gluten free for just about any ailment you can think of. There are a subset of people who are really sensitive to gluten, and they benefit greatly from a gluten free diet. But the large majority of people gain no direct gluten free benefit from this expensive and restrictive diet. One indirect benefit of the diet is that it is nearly impossible to eat pre-packaged and processed foods, which leaves real fruits, vegetables, and other high quality foods. (As more people are going gluten free there are more pre-package products made gluten free. I wonder if the benefits people have noticed previously will wane when they eat these foods. ) Talk with your doctor before deciding if going gluten free will work for your child.

Sugar is often blamed on hyperactivity. By all means, no child needs extra sugar, so cut out what you can. Well controlled studies did not find a behavioral difference in kids after refined sugars. Interestingly though, parents still perceived a change (despite researchers finding none) in at least one study (Wolraich, Wilson, and White. 1995).

Food allergies are now commonly thought to be related to behavior and learning problems. In some children with true allergies, foods can affect behavior. However, most children do not have food allergies and avoiding foods does not alter behavior. It can be challenging to determine if there is a food allergy since some of the tests offered are not reliable. It is a small subset of kids that food avoidance helps, but in the large majority studies do not support avoidance of foods. If you think your child benefits from avoiding one or two foods, it probably isn't a big deal to restrict those foods. But if you suspect your child is allergic to everything under the sun, you will need to work with your doctor and possibly an allergist and a nutritionist to determine exactly what your child must avoid and how they can get all the nutrients they need to grow and develop normally. 

Supplementation with vitamins, minerals, and essential fatty acids [arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexanoic acid (DHA)] is gaining popularity. There are some studies that show people with ADHD have low levels of certain vitamins and minerals. More studies are being done to determine if supplementing helps symptoms. There is growing evidence for vitamin supplementation, but there are no standard recommendations yet. For children without a known vitamin deficiency, a standard pediatric multivitamin can be used. Clinical trials using various combinations of high dose vitamins such as vitamin C, pantothenic acid, and pyridoxine suggest that these have no effect on ADHD. I don't recommend high dose vitamin supplements unless a specific deficiency is identified (and I don't routinely screen for deficiencies at this time). I have no problems with anyone taking a multivitamin daily, but cannot recommend any specific brand since none of them are regulated by the FDA and there are many reports that show the label often misrepresents levels of what is really in the bottle. My advice is to buy a brand that allows independent lab testing of their products if you choose to buy any vitamin or supplement.

The following is adapted from the University of Maryland Medical Center with the help of ADDitude Magazine and Natural Medicines Comprehensive Database.
  • Magnesium -- Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion. Some experts believe that children with ADHD may be showing the effects of mild magnesium deficiency. In one preliminary study of 75 magnesium-deficient children with ADHD, those who received magnesium supplements showed an improvement in behavior compared to those who did not receive the supplements. Too much magnesium can be dangerous and magnesium can interfere with certain medications, including antibiotics and blood pressure medications. Talk to your doctor. 
  • Vitamin B6 -- Adequate levels of vitamin B6 are needed for the body to make and use brain chemicals called neurotransmitters. These include serotonin, dopamine, and norepinephrine, the chemicals affected in children with ADHD. One preliminary study found that B6 pyridoxine was slightly more effective than Ritalin in improving behavior among hyperactive children - but other studies failed to show a benefit. The study that did show benefit used a high dose of B6, which could cause nerve damage, so more studies need to be done to confirm that it helps. If it is found to help, we need to learn how to monitor levels and dose the vitamin before this can be used safely outside of research centers. Because high doses can be dangerous, do not give your child B6 without your doctor's supervision. 
  • Zinc -- Zinc regulates the activity of brain chemicals, fatty acids, and melatonin, all of which are related to behavior. Several studies show that zinc may help improve behavior, slightly. Higher doses of zinc can be dangerous, so talk to your doctor before giving zinc to a child or taking it yourself.  
  • Iron -- Iron deficiencies can occur in children due to inadequate dietary sources (kids are picky!) and many other causes. Iron is needed for the synthesis of dopamine, norepinephrine, and serotonin- all neurotransmitters in the brain. Low iron has been linked to learning and behavior problems. Too much iron can be dangerous, so talk with your doctor if you want to start high dose supplements. (Regular multivitamins with iron should not cause overdose if used according to package directions.) It is important to follow labs to be sure the iron dose is not too high if supplementation with higher than standard doses of iron are given. For information on sources of iron in the diet, labs done to check for iron, and more, visit Iron Deficiency Anemia.
  • Essential fatty acids -- Fatty acids, such as those found in fish, fish oil, and flax seed (omega-3 fatty acids) and evening primrose oil (omega-6 fatty acids), are "good fats" that play a key role in normal brain function. The results of studies are mixed, but research continues. If you want to try fish oil to see if it reduces ADHD symptoms, talk to your doctor about the best dose. Some experts recommend that young school aged kids take 1,000-1,500 mg a day. Kids over 8 years should get 2,000-2,500 mg daily. For ADHD symptom control it is often recommended to get twice the amount of EPA to DHA.
  • L-carnitine -- L-carnitine is formed from an amino acid and helps cells in the body produce energy. One study found that 54% of a group of boys with ADHD showed improvement in behavior when taking L-carnitine, but more research is needed to confirm any benefit. Because L-carnitine has not been studied for safety in children, talk to your doctor before giving a child L-carnitine. L-carnitine may make symptoms of hypothyroid worse, and may increase the risk of seizures in people who have had seizures before. It can also interact with some medications. It should not be given until you talk to your child's doctor. It is not generally recommended at this time.
  • Vitamin C -- Vitamin C can help modulate the dopamine levels in the brain. It can affect the way your body absorbs medications (especially stimulants for ADHD) so it is best to avoid vitamin C supplements and citrus fruits that are high in vitamin C within the hour of taking medicines. Preliminary evidence suggests that a low dose of vitamin C in combination with flaxseed oil twice per day might improve some measures of attention, impulsivity, restlessness, and self-control in some children with ADHD, but more evidence is needed before this combination can be recommended.

  • Proteins -- Proteins are great for maintaining a healthy blood sugar and for keeping the brain focused. They are best eaten as foods: lean meats, eggs, dairy, nuts and seeds, legumes, and fish are high protein foods. Most people in our country eat more protein than is needed. If your child does not eat these foods in good quantity, there are supplements available, but talk with your doctor to see if they are appropriate for your child. Many of the supplements are high in sugar and other additives. Some have too much protein for children to safely eat on a regular basis.

In general I think we all should eat a healthy diet that is made up primarily of fruits, vegetables, lean proteins, and complex carbohydrates. If children are on a restricted diet due to allergy or sensitivities to foods or additives (or extreme pickiness), be sure to discuss their diet with your doctor and consider working with a nutritionist to be sure your child is getting all the nutrition needed for proper growth. If supplements are being considered, they should be discussed with your doctor so he or she can help decide which are right for your child.

More Quest for Health blogs on ADHD: