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:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

Remembering Vitamins and Medications

Compliance taking a daily medication (or vitamin) can be troublesome for many.  I find myself counseling parents and kids how to remember medicines often.  Here are my favorite tips:

• Use a pill box for pills. They come in various sizes and either single daily dosing or am/pm dosing, depending on your needs.  Pill boxes allow you to: 

1. be sure you have enough for the upcoming week,
2. remember if they were taken today,
3. keep several types of pills for each day together if taking more than one pill.  

• Liquid medicines: Wash the syringe after each use. Empty the dish drain of all contents daily so you find the syringe and remember to use it.  Or put a clean syringe in visible sight where you often look (tape it to the milk jug, in a glass next to the kitchen sink, in a glass near your coffee pot).  Remember the medicine needs to be out of reach from kids... not necessarily the syringe! 
• Refrigerated medicines: Put the medicine on a shelf that is eye-level, right in front. Don't let it get pushed to the back. Return the bottle to the fridge before giving the medicine to lessen the chance you leave it on the counter.  Remind older children that can access the refrigerator that the bottle is off limits!
• Keep medicine next to something you do daily (coffee, toothbrush). *Always keep out of reach of young children.*
• Use a specific glass that is unique that goes from table to dishwasher to table and never is put away.  Every time you empty the dishwasher, put water in the glass and set it on the table for medicine.
• Refill the medicine 1 week before you run out.  This allows you flexibility in case you forget to pick it up. It also allows recognition that there are no refills if that was missed, giving one week to see your doctor.  You can have enough for vacations if you routinely do this, since you can only fill one week earlier than the last fill... plan ahead if travelling!
• Keep tabs on number of refills left. The pharmacist should let you know with each refill how many are left. If there are none, call right then to set your next appointment if you haven't already.
• Set your phone or watch to alarm at the times the medicine is due.  Change the tone to one that is unique to remind you.
• Put a reminder on your calendar to call for refills and/or schedule appointments before the last minute.
• Leave sticky notes around the house or in your bathroom and kitchen if necessary!
• Keep some medication in your purse (or at the school nurse) to take if forgotten in the morning if this might still be a problem.  Remember to not leave your purse in the car or other places the medicine will get too hot or cold.  If the school nurse will keep some, be sure to ask for a nurse's note when getting the prescription.
• If you travel often, it helps to keep an empty pill box in your toiletry bag, so when packing it you see the empty box that needs to be filled.  Or you could put a sticky note in the toiletry bag reminding you to pack them.
• Grab a pen/marker and draw a "calendar" (Mon am/pm, Tues am/pm, ...) on the bottle with space to check off when you've given the medicine each day. 

Regular prescription medications goes hand in hand with regular follow up with your doctor to manage the medication dosing. This is important for many reasons, so I try to give as many refills that will be needed until the next visit.  Ask your doctor how they handle refills before the medicine runs out so there are no delays in treatment.  Remember to schedule your next visit!

• If able, schedule the next visit before you leave the doctor's office.  Bring your calendar to each visit!
• Call as soon as you can to schedule if you don't have your calendar available at the doctor's office or you were unable to schedule for any reason.
• If you notice no more refills on the bottle when picking up your medicine, call that day to schedule an appointment.  The later you wait, the fewer appointment times will be available. Early morning and later in the day fill first!
• If you are filling the prescription at a time that your doctor's office is closed, look for options for them to call you.  Some offer online appointment requests.  You can request appointments from our website at any time day or night. Leave the best numbers for us to call during business hours.  Many offices have a voice mail that allows leaving a message for them to call you to schedule an appointment.

Once habits form, it is easier to remember, but until then be sure to set reminders-- especially if the medication must be taken at a certain time each day or if missed doses can be dangerous.  Learn what to do if you forget a dose by talking with your doctor or pharmacist. Some medicines are fine to skip a dose, others are not so forgiving and must be taken as soon as remembered.  

I hope this helps!  What tricks have you learned to remember your medicines?

Excessive milk can cause anemia? How?

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk.  Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer:  Cow's milk has little iron.  When kids drink a lot of milk, they don't eat iron-containing foods in sufficient volumes.  Cow's milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut

                              but less blood produced because less iron in the diet

                                                 = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies.  Too few red blood cells in the body is called anemia.  Red blood cells are made in our bone marrow and they live for about 3 months.  It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

• too little blood produced (iron deficiency being a major risk for this)
• increased blood loss (ie excessive bleeding)
• increased destruction of blood cells in the body (typically from abnormal blood cells or infection)

Iron deficiency can be due to several factors:

• poor iron absorption due to disease (some studies show milk inhibits iron absorption)
• poor iron in the diet (the most common cause)
• long term slow blood losses (such as heavy monthly periods or GI bleeding)
• increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter? Because the most common symptom of anemia is no symptoms.  It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.  Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother's milk.  Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason.  Cow's milk, soy milk, and goat's milk are not acceptable for infants due to the nutritional voids they have (not just iron).  After about 1 year of age babies tend to wean from mother's milk and/or formula onto whole milk.  (Newer recommendations allow weaning onto low fat milk--another topic entirely.)  Unfortified non-human milks contain very little iron.  The iron in human milk is better absorbed and iron is supplemented into formula.  If toddlers and children drink too much milk, they fill up on it and don't eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

• meats and poultry (especially organ meats, such as liver)
• lentils, peas, and dried beans
• eggs
• oysters, clams, and fish
• molasses
• peanut butter
• soy
• pumpkin or sesame seeds
• fruits such as prunes, apricots, and raisins
• vegetables such as spinach, kale, broccoli, and other greens
• whole grain fortified breads and cereals

Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!

Complimentary and Alternative Medicine

Complimentary and Alternative Medicine (CAM) means many things to many people, but the truth is  that many people use it to try to help a broad range of ailments without much guidance from their physicians.

Why?  Reasons vary.  Some feel that "natural is better."  Others feel that mainstream medicine is not working.  Many people see CAM as a lifestyle choice.  Some don't have access to (or money for) a doctor visit, and CAM is readily available at many locations.  There are many other reasons that people use CAM.

Is it safe? Is it reliable?  Depends on the CAM.

What is CAM?

CAM includes any form of medical treatment that is not a part of mainstream medicine.  It has gained popularity because it is holistic, and people like the idea of treating the whole person and not simply one condition.  It includes many categories of treatments, including natural products (vitamin supplements, herbal medicines, minerals, and probiotics), homeopathy (diluted substances that would typically cause symptoms used to treat those symptoms), acupuncture and manipulative treatments, Oriental medicine (energy fields), and mind-body medicine.

What are potential problems with CAM?

• Homeopathic medicines and natural products are not regulated by the FDA.

• Some therapies have been shown to be contaminated with heavy metals (such as lead)
• Products have been shown to be inconsistent in the amount of active ingredient from bottle to bottle
• Studies to show the appropriate dose have not been done in most instances 

•  Studies to show effectiveness have not been done in many cases

• Many don't share CAM use with their physicians.  Why?

• Don't want to admit in case doc disagrees

• Don't think about it and aren't asked specifically 

• Don't think it will make a difference

• Many docs don't know how to advise about CAM.

• If parents ask about herbs, spinal manipulation, or other CAM treatments, physicians often don't have the answers.  
• Physicians are taught to advise based on an evidenced based platform.  If studies haven't shown a treatment to benefit, we are less likely to recommend it. For many complementary and alternative medicines studies have not been done to show safety and efficacy.  
• Studies that have been done typically were done in adults, not children.  Children handle medicines and therapies differently than adults, but research is often not done on them. 

• CAM information does not often make news in medical journals and is not typically discussed at conferences, the places at which your physicians learn. 

Do I recommend CAM?


While there are many CAM treatments that I am not comfortable recommending, I often recommend things that are CAM.

The first and foremost form of alternative medicine I recommend to everyone is healthy diet and lifestyle.  This is widely accepted among mainstream medical doctors.  Healthy diet and exercise helps prevent many health problems, treat some health problems, and even helps mental focus and overall mental health.  

I believe there is solid research supporting fish oil, probiotics, and other vitamin supplements.  The American Academy of Pediatrics recommends Vitamin D for all children. 

I think that relaxation techniques, biofeedback, yoga, prayer, and meditation can all be beneficial and I cannot see how they would be detrimental if used properly.  

In the category of manipulative medicine, I have not been trained specifically, but I refer to physical therapists and sometimes chiropractors.  Massage therapy is a growing field, and has been recommended for children with muscle tightness affecting gait and for those with sports injuries.

Other CAM therapies are difficult for me to recommend.

Herbal therapies might be beneficial, but there is also potential risk of interactions with other therapies.  They are not regulated by the FDA and have been known to be contaminated with things such as lead. There also have been reports of the strength of the supplement to vary widely from what is listed on the bottle and non-listed ingredients to be in the supplement.  This can lead to unknown interactions and consequences.

Most studies of CAM therapies have been done on adults.  Children are not little adults.  Therapies such as lifestyle changes are safe, but those with herbal or homeopathic medications might not be.  There simply is not enough scientific data to support the use of these in children.

Studies do show that about 50% of children have used complementary or alternative medicine (higher numbers if you include vitamin supplements).  Unfortunately most of the time the physician is unaware of these treatments.  Many of the kids using these therapies are those with chronic conditions for which there is no traditional medical therapy that manages the condition well.  This means that more research is needed to show if they are safe or effective.  Are they worth the cost? Is there something better? Should physicians recommend them because they do work?

Why would parents use a treatment that isn't proven? They just want to help. Many parents think "natural" is better.

My answer to that: I would never give my kids organic marijuana to stimulate their appetite.  It is natural.  Organic even.   And it does stimulate the appetite, so it might work.  But I know there are risks to marijuana.  We've all heard those because it is a well known (and unfortunately misused) substance.  Many herbs and other treatments aren't as well known.

How to improve the safety of CAM use in your children:

• Discuss any therapy you are using with your health care provider. If you have more than one provider, be sure all know each treatment you are using.
• If you use a CAM provider, be sure to check the education and training of that person.  Are they licensed to practice?  Be sure they have experience with the age group of your child.  (This actually goes for any health care provider you choose!)
• Ask your pharmacist if there are any known interactions with the supplements and medications you are giving your child.  Be sure to list all prescription, over the counter, and supplements given.
• Store all medications, supplements, and vitamins out of reach of children.
• If you notice any ill effects that might be related to CAM or other treatments, be sure to discuss with your provider!

Resources:

AAP News 2008; 29;1
PEDIATRICS Volume 120:1, July 2007
PEDIATRICS Volume 125:2, February 2010
National Center for Complementary and Alternative Medicine (NCCAM)