Recent research (1,2) on children and adolescents has reported that elevated levels of ADHD symptoms are positively associated with unhealthy dietary habits, including a higher consumption of refined sugars, processed food, soft drink, instant noodles, and a lower intake of vegetables and fruits. However, the link between low-quality diets and risk of ADHD in adults is still not well established, which would be further explored in the ongoing Eat2beNICE research project.

What is the underlying mechanism for an association between ADHD and unhealthy dietary habits? There is still no clear answer. Nemours’ potential biological pathways, by which dietary intake could have an impact on mental health, has been proposed in the literature (2). For example, iron and zinc are cofactors for dopamine and norepinephrine production (essential factors in the etiology of ADHD), so unbalanced diet with lower levels of iron and zinc may further contribute to the development of ADHD. However, we cannot overlook the possibility of a bi-directional relationship between diet quality and ADHD, especially when the interest in the concept of “food addiction” has received increased attention.

Food addiction refers to being addicted to certain foods (e.g. highly processed foods, highly palatable foods, sweet and junk foods) in a similar way as drug addicts are addicted to drugs. Animal models (3) have suggested that highly processed foods may possess addictive properties. Rats given high-sugar or high-fat foods display symptoms of binge eating, such as consuming increased quantities of food in short time periods, and seeking out highly processed foods despite negative consequences (e.g. electric foot shocks). One human study (4) found that individuals with high levels of ADHD-like traits (e.g. high levels of impulsively, disorganised, attention problems) were more likely to suffer from problematic eating behaviour with overconsumption of specific highly palatable foods in an addiction-like manner. Therefore, food addiction may, just as substance abuse, be over-represented among individuals with ADHD.

Thus, it seems there could be a vicious cycle between unhealthy dietary habits and ADHD: ADHD may lead to a worse choice of diet, lowering the health quality, which could eventually exacerbate ADHD symptoms. We will further test the bidirectional diet-ADHD associations in the ongoing Eat2beNice project.

This was co-authored by Henrik Larsson, professor in the School of Medical Science, Örebro University and Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden.

AUTHORS:
Lin Li, MSc, PhD student in the School of Medical Science, Örebro University, Sweden.
Henrik Larsson, PhD, professor in the School of Medical Science, Örebro University and Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden.

REFERENCES:
1. Kim KM, Lim MH, Kwon HJ, Yoo SJ, Kim EJ, Kim JW, et al. Associations between attention-deficit/hyperactivity disorder symptoms and dietary habits in elementary school children. Appetite. 2018;127:274-9.

2. Rios-Hernandez A, Alda JA, Farran-Codina A, Ferreira-Garcia E, Izquierdo-Pulido M. The Mediterranean Diet and ADHD in Children and Adolescents. Pediatrics. 2017;139(2).

3. Gearhardt AN, White MA, Potenza MN. Binge Eating Disorder and Food Addiction. Curr Drug Abuse Rev. 2011;4(3):201-7.

4. Ptacek R, Stefano GB, Weissenberger S, Akotia D, Raboch J, Papezova H, et al. Attention deficit hyperactivity disorder and disordered eating behaviors: links, risks, and challenges faced. Neuropsychiatr Dis Treat. 2016;12:571-9.

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A little while ago, this blog featured an entry by Annick Bosch on the TRACE study, an amazing intervention study using the Elimination Diet to treat ADHD in kids (https://newbrainnutrition.com/adhd-and-elimination-diet/). Very shortly summarized, the Elimination Diet entails that participants can only eat a very restricted set of foodstuffs for several weeks, which can greatly reduce the number of ADHD symptoms in some kids. Subsequently, new foodstuffs are added back into the diet one by one, all the time checking that ADHD symptoms do not return. This ensures that every child for which the Elimination Diet proves successful ends up with a unique diet which suppresses their ADHD symptoms.

Now this is a fascinating study, since it indicates a direct influence of diet on ADHD behavior. What we know from the neurobiology of ADHD, is that it is caused by a myriad of relatively small changes in the structure, connectivity and functioning of several brain networks 1. For the most common treatments of ADHD, like medication with methylphenidate 2, we can quite accurately see the changes these interventions have on brain functioning. However, for the Elimination Diet, this has not been studied before at all. This is why we are now starting with the TRACE-MRI study, where kids that participate in a diet intervention in the TRACE program, are also asked to join for two sessions in an MRI scanner. Once before the start of the diet, and once again after 5 weeks, when the strictest phase of the Elimination Diet concludes. In the MRI scanner, we will look at the structure of the brain, at the connectivity of the brain, and at the functioning of the brain using two short psychological tasks. We made a short vlog detailing the experience of some of our first volunteers for this MRI session.

 

 

With the addition of this MRI session, we hope to be able to see the changes in brain structure and function over the first 5 weeks of the diet intervention. This will help us establish a solid biological foundation of how diet can influence the brain in general, and ADHD symptoms specifically. It can also show us if the effect of the Elimination Diet is found in the same brain networks and systems which respond to medication treatment. And lastly, we can see if there is a difference in the brains for those participants for whom the diet has a strong effect versus those where the diet does little or nothing to improve their ADHD symptoms. This can then help us identify for which people a dietary intervention would be a good alternative to standard treatment.

We will update you on the TRACE-MRI study and on the developments in this field right here on this blog!

 

REFERENCES
Faraone, S. V et al. Attention-deficit/hyperactivity disorder ­­­. Nat. Rev. Dis. Prim. 1, (2015).

Konrad, K., Neufang, S., Fink, G. R. & Herpertz-Dahlmann, B. Long-term effects of methylphenidate on neural networks associated with executive attention in children with ADHD: results from a longitudinal functional MRI study. J. Am. Acad. Child Adolesc. Psychiatry 46, 1633–41 (2007).

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When Alice’s mother first contacted our team to get more information on the dietary intervention at New Brain Nutrition, she mentioned that her daughter seems to be on edge all the time. On a typical day, Alice would be triggered easily over seemingly small things and stay upset for a long time. She told us that these emotional problems caused not only very strained and cheerless moments on the weekends and evenings, they also interfered notably with Alice’s social life. In between her angry or sad moments, Alice seems to be a perfectly happy and energetic 11-year old. Alice’s attention problems didn’t obstruct a healthy didactic development since she started ADHD-medication. However, the emotional problems were still present and seemed to cause severe impairment in social interactions, within the family and with peers. Therefore, her mother asked: Could we please try a dietary intervention to see if Alice’s nutrition may play a role in these problems?

Faraone[1] distinguishes two features in these kind of emotional problems: Emotional Impulsivity and Deficient Emotional Self-Regulation. Some children may experience explosive anger but also recover quickly from it. These children experience high Emotional Impulsivity but low Deficient Emotional Self-Regulation. Alice however, based on her mother’s narrative, seems to experience both high Emotional Impulsivity and high Deficient Emotional Self-Regulation.

The second week into the Elimination Diet treatment, the researcher checks in with the family: She’s still edgy and irritable for most of the time, her mother says, but she seems to break out of it a whole lot sooner. The other day her brother Daniel came home, telling Alice he ate lots of non-elimination diet snacks at his friend’s house. Understandably, Alice became upset but it didn’t last as long as her parents expected. In other words: The Emotional Impulsivity hadn’t decreased yet, but the Deficient Emotional Self-Regulation had.

By the end of the first 5 weeks of the dietary intervention, Alice’s parents reported a convincing decrease in emotion regulation problems. The teacher also reported that the attention problems had stabilized, as much as they did with the ADHD-medication that Alice had before. The family decided to continue the Elimination Diet and start with the re-introduction phase. Every two weeks a new product was re-introduced to see if this may elicit symptoms. This was probably the most interesting period for the family, as emotion regulation problems and attention problems arose and subsided over different phases.

After one year, Alice and her family had figured out a set of foods that, when eliminated from her diet, helped diminishing both the attention problems and emotional problems. Alice is less responsive to emotional triggers and more balanced during social interactions. Alice’s personalized diet or personalized nutrition is based on her experiences and symptoms during the dietary intervention. Her mother is very glad that they discovered this lifestyle intervention as an alternative to their previous treatment with ADHD-medication.

Writers note: This is the story of one individual participating in the New Brain Nutrition study. Evaluating the role of nutrition in treatment of mental health with scientific evidence is part of our future.

More information can be found in [1] Faraone S.V., Rostain A.L., Blader J., Busch B., Childress A.C., Connor D.F., & Newcorn J.H. (2018). Practitioner Review: Emotional dysregulation in attention‐deficit/hyperactivity disorder – implications for clinical recognition and intervention. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.12899

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In studies about treatment for children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), it is important to use valid and reliable instruments to measure effects. A valid instrument can measure a difference in symptoms before and some time after the treatment has started. Usually questionnaires for parents and teachers are used.

In the TRACE project, currently running in the Netherlands, we are looking at the effectiveness of a dietary intervention versus care as usual, for children diagnosed with ADHD in the age group of 5-12 year old. In addition to the standard questionnaires, there is an observation instrument called the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS). This instrument was added in the TRACE project as an objective measurement for changes in behavior.

DB-DOS, ADHDThe DB-DOS was originally developed to measure disruptive behavior disorders (DBD) in preschoolers1. This way, treatment effects are not only measured in an indirect way, through information of caregivers, but also in a direct observation in the clinical setting. However, the age range of the children in the TRACE project is different from the preschoolers the DB-DOS was originally intented for. That’s why the TRACE project added several tasks to the original DB-DOS, to make sure it elicits disruptive behaviours, as well as hyperactivity and impulsivity, and to make it suitable for older children. During the current trial we try to find out if the DB-DOS is also a valid measurement for older children, aged 5-12 years.

The DB-DOS uses three different interactional contexts: parent-child context, examiner-child context and parent-examiner-child context. Children will be asked to complete different tasks. Some are rather boring, or frustrating, to see if this may elicit attention problems, hyperactivity, impulsive behaviour or disruptive behaviors. The DB-DOS contains, for example, some tasks which can evoke anger or sadness and some tasks where children get the chance to cheat. The reaction of the child is observed from behind a one-way screen. The observation lasts about 60 minutes and afterwards the observed behavior is scored by the examiner through a coding system. With more evidence-based instruments, mental health problems can be targeted more efficiently and reliably.

Our final goal is earlier interventions which prevent mental health problems in these children getting more severe and spreading through other domains such as school, work, or social contacts.

We will keep you posted about the results of the DB-DOS in the TRACE project!

REFERENCE
1 Bunte, T. L., Laschen, S., Schoemaker, K., Hessen, D. J., Van der Heijden, P. G. M., & Matthys, W. (2013). Clinical Usefulness of Observational Assessment in the Diagnosis of DBD and ADHD in Preschoolers. Journal of Clinical Child & Adolescent Psychology, 42(6), p.p. 749-761.
http://dx.doi.org/10.1080/15374416.2013.773516

 

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