I have noticed a growing number of companies offering to measure nutrient levels and then offering a personalized treatment approach to address deficiencies identified. I have also been sent individual blood results from members of the public and asked whether the results can be used to direct the best treatment. Others contact me and tell me their nutrient levels are “normal” so their doctor told them there was no need for additional nutrients.

It is a reasonable question because there are many studies that suggest that people with psychological problems such as ADHD have lower levels of nutrients in their blood relative to the nonclinical population. What we don’t know is whether it is necessary to be deficient in order to benefit from additional nutrients than what you can get out of your diet.

So what does the research say?

Our lab at the University of Canterbury in New Zealand is one of a few that has specifically investigated whether nutrient levels are predictive of response to a broad spectrum micronutrient intervention. It is important to note that not many labs take this approach, that is giving a combination of nutrients together and then assess treatment response. Many researchers make the assumption that one must be deficient to benefit from nutrients, and therefore select people for the deficiency and only treat them. We treat everyone, regardless of identified deficiency, and then assess whether the deficiency predicts who will respond and who won’t.

Overall, our research shows that the effect, if there is one, is weak, and certainly not useful at an individual level as a good predictor of treatment outcome.

Here is what we did: We assessed some key nutrients pre-treatment via serum/plasma. We measured vitamin B12, vitamin D, zinc, copper, folate, ferritin, potassium, sodium, calcium, and homocysteine. We have looked at two data sets – an adult study and a child study, both comparing vitamins/minerals to placebo in the treatment of symptoms associated with ADHD.

Findings from the adult ADHD trial:

Participants improved significantly on all outcome measures after exposure to the micronutrients for 8 weeks; 61% were identified as responders.

But, there was no relationship between baseline functioning and baseline nutrient levels. This was a bit surprising given that studies have identified deficiencies in magnesium, zinc and iron in children with ADHD. Surprisingly, we didn’t find that these nutrient levels were highly correlated with ADHD symptoms.

Very few predictors were identified. We found that greater pre-treatment with ferritin predicted who would be an ADHD responder. We wondered if those with higher ferritin had higher inflammation and therefore responded more rapidly to the treatment as the micronutrients may have improved inflammation.

Lower pre-treatment vitamin D predicted greater change on a measure of mood. This finding is not unexpected as low vitamin D levels have been associated with low mood. Pre-treatment copper gave us a signal, but it was weak and mixed.

Micronutrient supplementsIt is important to note that while there were these small signals, there were still many people with normal levels of these nutrients who benefitted from the nutrient approach, only there were fewer relative to those with vitamin D and copper deficiencies.

No other relationships between baseline nutrient levels and treatment response were identified. In other words, zinc, iron and vitamin B12 pre-treatment did not predict who would benefit and who would not. Further, there were no specific demographic variables (age, socio-economic status, gender, marital status, education) which contraindicated micronutrient treatment for ADHD in adults.

Findings from the child trial:

We identified that 49% of the children responded to the micronutrient intervention. Substantial nutrient deficiencies pre-treatment were observed only for vitamin D (13%) and copper (15%), otherwise most children entered the trial with nutrient levels falling within expected ranges. Lower pre-treatment folate and B12 levels, being female, greater severity of symptoms and co-occurring disorders pre-treatment, more pregnancy complications and fewer birth problems were identified as possible predictors of greater improvement for some but not all outcome measures although predictive values of all of them were weak. Lower IQ and higher BMI predicted greater improvement in aggression.

It is important to note that levels of folate pre-treatment for ADHD responders was within the normal reference range for folate (>8nmol/L). In other words, the blood tests did not identify responders as deficient in folate, just lower relative to non-responders. Note though, that there were many children with higher B12 and folate who did benefit from the nutrient treatment. No other relationships between pre-treatment nutrient levels and treatment response were identified.

It is also important to point out that across two studies, replication did not occur and any findings we did observe were incredibly modest. As such, they could not be used at an individual level to reliably identify who might benefit from this treatment approach. We see this as good news as it means people don’t have to feel they need to get expensive testing done before trying nutrients. The bad news is that the search is still on to figure out why some people respond and some don’t.

Although not reported in these trials, we have also looked at the predictive value of nutrient levels recorded from hair samples and similarly, the levels were also not overly helpful at predicting treatment response.

Do nutrient levels have to change for benefit to occur?

Now this is a tricky question. But we have now published a study looking at this very question, that is, whether change in a nutrient biomarker is correlated with improvement in mental health. Our overall findings were that they were not.

I think this type of question stems from research in medicine such as physicians tracking cholesterol levels in order to determine whether they are associated with the progression of disease (such as incidence of stroke). Change in cholesterol levels are used to estimate risk for future cardiovascular events.

In the mental health world, at best, they are weakly correlated with improvement in symptoms and probably not that helpful. We investigated whether changes in serum nutrient levels mediate clinical response to a micronutrient intervention for ADHD. Data were compiled from two ADHD trials (8-10 weeks), one in adults (n = 53) and one in children (n = 38). Seven outcomes included change in ADHD symptoms, mood, overall functioning (all clinician-rated) as well as response status. Change in serum/plasma nutrient levels (vitamins B12 and D, folate, ferritin, iron, zinc, and copper) were considered putative mediators.

We found that a decrease in ferritin and an increase in copper were weakly associated with greater likelihood of being identified as an ADHD responder; none of the other nutrient biomarkers served as mediators. Perhaps we need to look to see if other tissue (like hair or microbiome samples) might be more useful. Monitoring these biomarkers is unlikely helpful in understanding clinical response to a broad-spectrum micronutrient approach.

Blood levels don’t necessarily tell us what is going on in the brain and what nutrients are being used and what isn’t being used. We didn’t look at ALL nutrients so it may be we missed an important biomarker. It may be ratios are more important. But next time a professional is keen to track nutrient levels as a proxy for response, perhaps be a bit sceptical about whether the data support such testing.

Is the term deficiency accurate?

The term “deficiency”, as is often used in the ADHD literature when discussing nutrient levels, may be problematic. Although research shows that the ADHD group mean nutrient levels are often below control group means, the ADHD means are typically still falling within the normal reference range, potentially challenging the use of the term “nutrient deficiency” when attempting to investigate causes of ADHD and in relation to predicting response to nutrients. Given that reference ranges are generally defined as the set of values that 95 percent of the normal population falls within, this does not necessarily mean that these ranges are best equipped to identify what is required for optimal health for any particular individual.

Had functional ranges (the range used to assess risk for disease before the disease develops) been used in these studies, many more would have been identified with “deficiencies”. An important hypothesis which requires further investigation is that some individuals may have suboptimal nutrition for brain health despite having nutrient levels within the reference range. In other words, they might have a nutrient deficiency relative to their metabolic needs rather than relative to general population levels.

It is exciting that the EAT2BeNice consortium (NewBrainNutrition) will be looking at nutrient levels alongside other biomarkers so we can confirm whether these results are replicable. Hopefully some of the other biomarkers will prove more useful at predicting treatment response. Afterall, it is a valid clinical question to wonder – when a treatment works, who does it work for and why? These types of data inform clinical practice and can help the consumer decide whether you should go for that expensive testing, or not bother. At this stage, I wouldn’t bother.

References

  1. Rucklidge JJ, Johnstone JM, Gorman B, Boggis A, Frampton CM. Moderators of treatment response in adults with ADHD treated with a vitamin-mineral supplement. Prog Neuropsychopharmacol Biol Psychiatry. 2014;50:163-71.
  2. Rucklidge JJ, Eggleston MJF, Darling K, Stevens A, Kennedy M, Frampton CM. Can we predict treatment response in children with ADHD to a vitamin-mineral supplement? An investigation into pre-treatment nutrient serum levels, MTHFR status, clinical correlates and demographic variables. Prog Neuropsychopharmacol Biol Psychiatry. 2018.
  3. Rucklidge JJ, Eggleston MJF, Boggis A, Darling K, et al. Do Changes in Blood Nutrient Levels Mediate Treatment Response in Children and Adults With ADHD Consuming a Vitamin–Mineral Supplement? Journal of Attention Disorders. 2019. 0:1087054719886363.

 

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Meet Tim: he is an 8-year-old boy, living in the Netherlands with his parents and younger sister. A couple of years ago, Tim was diagnosed with Attention Deficit Hyperactivity/Impulsivity Disorder (ADHD). His psychologist recommended to participate in the TRACE study: this study examines the short- and long-term effects of dietary treatments in children with ADHD. In addition, the TRACE-BIOME study examines the underlying mechanisms of a dietary treatment. For this, we collect blood, stool and saliva samples and we perform a fMRI. These measurements might, among other things, shed light on the role of the brain-gut-axis.

But what’s it like to participate in a clinical trial? First of all, Tim was allocated to one of the two TRACE dietary treatments: an elimination diet or a healthy diet. Tim was allocated to the elimination diet. If we want to know if this diet is effective for Tim, we have to do a lot of different assessments (Figure 1).

Figure 1: assessments TRACE study
The TRACE Study, New Brain Nutrition

 

 

 

Before the baseline, 5 week and 1-year assessments, a couple of measurements already take place:

  • Tim wears an Actigraph one week before the assessment, which measures motor activity and sleep-wake rhythm;
  • Parents collect a stool sample from Tim in which his microbiota can be assessed;
  • Parents and teachers fill out different questionnaires about Tim’s behavior, but also about for example parenting styles;
  • Parents keep track of a food diary: what does Tim eat during two weekdays and one weekend day?

Before starting the elimination diet, Tim’s parents have a consult with one of the TRACE dieticians, so that they can prepare changing the diet of Tim. Then, it is time for the baseline assessment. Tim and his mother meet the researcher at the hospital for the blood venipuncture. He also has to chew on a cotton pad to collect a saliva sample. After this, they walk to Karakter which is a center for Child and Adolescent Psychiatry. The researcher measures his weight, length, blood pressure and heart rate. Next, Tim has to perform a task on the laptop which he really likes! This task assesses cognitive functions such as sustained attention, working memory and cognitive flexibility. After the computer task there is time for a break. Next, they start with a behavioral observation. In this task, Tim first plays with his mother and then with the researchers. The different tasks try to elicit ADHD symptoms and emotion (dys)regulation behavior. Finally, the MRI researcher takes Tim and his mother to the fMRI scanner in which he has to do two different tasks. All in all, the assessment takes about 4 hours.

After 5 weeks of the diet, it is time for the second assessment which is the same as the baseline assessment. The researcher has calculated, based on the parent and teacher questionnaires, if there is a significant response to the diet. Tim shows a 40% reduction of ADHD symptoms, which is a significant response! Therefore, they continue the diet. After 4 and 8 months of the diet, his parents receive some online questionnaires. Finally, after one year they are invited for the final assessment, which is again the same as the baseline assessment (without the fMRI).

 

The following YouTube video explains the assessments described above, in Dutch: ADHD en voeding: TRACE-onderzoek testdag

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When we are under high stress, we can often reach for foods that are “comforting” (like cookies, donuts, cake, pastries, and chocolate bars), but these foods may not be the best choice for feeding your brain under stressful and demanding circumstances. Comfort foods are often calorie-rich but nutrient-poor.

Further, under high stress (and it doesn’t actually matter what has caused the high stress, whether it be a natural disaster like an earthquake or fire, or witnessing something really traumatic), the reactions our body goes through can be quite similar. We release adrenaline. This is part of our natural alarm response system.

Adrenaline is an essential neurotransmitter that is released as part of the fight-flight response. It enables our body to get us to safety, shut down non-essential functions, and make sure the muscles needed for fight or flight get activated. Cortisol, a hormone, is also essential for the alarm system to function optimally.

Unfortunately, over extended periods of time, the alarm system can go into over-drive, and this is one factor that can lead to re-experiencing memories, flashbacks, hypervigilance, being on edge all the time, feeling anxious and panicky when reminded of the traumatic event, struggling with sleeping and having nightmares.

Making neurotransmitters and hormones requires micronutrients, which are numerous kinds of vitamins and minerals. This is a well-established scientific fact. Micronutrients like zinc, calcium, magnesium, iron, and niacin are all essential for making neurotransmitter chemicals for the brain and the body. If your body is depleted of these nutrients, then either it won’t have sufficient nutrients to make these essential chemicals, or it will redirect all resources to the fight or flight response (as it is so vital for survival) and there won’t be much left for ensuring optimal brain function to do things like concentrate, regulate moods and sleep.

Consequently, as micronutrients get depleted at a high rate during times of stress, we need to replenish them in greater quantity from our food (and perhaps other sources).

Where can we get these micronutrients from?

Answer: Nutrient-dense foods; real food, not ultra-processed foods.
Compare a banana to a cookie; one obtains far more of these micronutrients (like potassium, magnesium, folate) that are required for brain function from a banana. Eating kale chips over potato chips would also provide more nutrients. Reaching for a carrot stick and dipping it in hummus would be better for your brain than gorging down a commercial meat pie (although meat pies can be healthy if they contain lots of vegetables too). Choosing nuts and seeds over pretzels would also give you better brain food.

Overall, to cope well with stress your goal should be to increase intake of plant food and food high in nutrient density while still getting adequate protein, fats and carbs. Fish is a great source of protein and of essential fatty acids, which are also vital for brain function. In eating these types of foods, you would be shifting your diet from a Western type of diet (ultra-processed, high in sugar) to a Mediterranean-style diet (high in fruits and veggies, fish, nuts, healthy fats and low in processed foods).

Therefore, stop counting calories and start focussing on nutrients, especially nutrients that are good for your brain!

Would this be sufficient to sooth the over-activated alarm system in a situation of high and chronic stress? Possibly, although some people might need more nutrients than what they can get out of their diet, even if it is a healthy one. There are many reasons for this, some of which reflect reduced nutrient density in modern foods, some of which are due to our own specific genetic make-up, and some have to do with the health of our microbiome (the millions of helpful bacteria that live inside us, especially in our gut).

If you do need to consume more nutrients than what you can source from your diet, or you are struggling with cooking due to your particular circumstances and the stresses you are experiencing, or you are time poor because of family or work demands, what do you take in terms of a supplement? Research from the Mental Health and Nutrition Lab in Christchurch, NZ found that following the Christchurch earthquakes as well as other research on stressed communities shows that B vitamins, in particular, can be helpful. A recently published meta-analysis confirmed the positive effect of B vitamins on reducing stress. In addition, some may find a reduction of intrusive thoughts require additional minerals as well.

Nutrition resources for psychologists and mental health professionals working with people struggling with anxiety post-trauma:

When working with people struggling with stress/anxiety, research shows that it is essential that their diet includes foods that are nutrient-dense. This means being aware of foods that are high in vitamins and minerals as well as being a good source of fats, proteins and carbohydrates.

You can ask some simple questions:

  • How many times a week do you eat fast food meals or snacks?
  • How many regular fizzy drinks do you drink each day?
  • Snacks? Favourite Foods? Problem Foods?
  • Any restrictions? Allergies? Aversions?
  • How many servings of fruit do you eat each day?
  • How many servings of vegetables do you eat each day?
  • How often do you eat red meat (good source of iron, folate)?
  • Do you eat fish? (good to know if they are vegan, vegetarian, or gluten-free)

These questions can start the conversation to find out if they are eating nutrient dense foods.

Here are some basic tips:

  1. Start with whole foods diet approach including good fats, nuts, seeds, fish, a modest amount of meat, vegetables, fruit, whole grains
  2. Shifting towards eating “real” as opposed to processed foods naturally eliminates unnecessary food additives such as artificial colours, flavours, sweeteners and preservatives that do not add nutritional value and may contribute to psychiatric symptoms in some people
  3. Limit sugar intake (sugar is everywhere in processed foods, energy/fizzy drinks – encourage clients to look at labels to spot the hidden sugar)
  4. watch caffeine and alcohol intake doesn’t creep up
  5. Eat a good solid nutrient-dense breakfast: e.g., omelette with vegetables, muesli (oats, nuts, raisins) with milk, yogurt, fresh fruit
  6. If your client is struggling with cooking or a change in diet is not working enough to reduce psychological symptoms, you can consider suggesting supplements as there has been a lot of research on them. If suggesting supplements, stick to the data and published research, the best research is on adding additional B vitamins (like Blackmores or Berocca). For more information please email the Mental Health and Nutrition Research Group: mentalhealthnutrition@canterbury.ac.nz

Here are some useful resources:

A recent radio interview about dietary patterns and stress: https://www.radionz.co.nz/national/programmes/nights/audio/2018687489/nutrition-during-times-of-stress-and-trauma

Harvard Medical School has put together lots of resources on healthy eating, including the healthy eating plate: www.health.harvard.edu/staying-healthy/healthy-eating-plate

The Helfimed trial was a successful trial that showed the benefit of assisting people suffering from depression to nudge over to a more Mediterranean-based diet. They have lots of recipes on their website: http://helfimed.org/cgi-sys/suspendedpage.cgi

The Mood and Food Centre in Melbourne often blogs on diet-related topics. Check out their website: http://foodandmoodcentre.com.au/

Dr Drew Ramsey has some excellent resources on eating well on a budget: https://drewramseymd.com/uncategorized/brain-food-budget/

There are lots of great resources at this site: https://www.getselfhelp.co.uk/freedownloads.htm

Books that we have enjoyed reading on nutrition and mental health that do have some scientific basis to their recommendations:

  • Brain Changer – Prof Felice Jacka
  • Finally Focused – Dr James Greenblatt
  • The Mad Diet – Suzanne Lockhart
  • The anti-anxiety food solution –Trudy Scott
  • What the FAT? – Prof Grant Schofield (also includes recipes)

Rachel Kelly has devised a cookbook directly focused on eating foods that will contain nutrients help you feel mentally better:

https://www.rachel-kelly.net/books-apps/

How to eat well on a budget:
From the British Dietetic Association: A healthy diet can be more expensive than a diet made up of more refined foods. Fish, fruit and vegetables can be particularly pricey. However, by cutting down on sugary drinks and snacks, takeaways and alcohol, you can save money to be spent on healthier items. Take care to buy only as much as you know you can use within the next few days to reduce waste. You can also cut your costs by taking advantage of special promotions and by shopping at market stalls which are often cheaper than supermarkets.

If you live alone you could save money by splitting purchases with friends (larger pack sizes are usually cheaper) or by cooking several portions of a dish and freezing some of them. This also saves fuel and saves you the effort of preparing meals every day. Frozen fruit and vegetables are often cheaper than fresh produce and are usually just as good nutritionally (with no wastage). Fresh fruit and vegetables are usually cheapest when they are in season.

Also, research from Australia has shown that a Mediterranean style diet was cheaper than a poor quality diet.

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Stress tends to mess with our eating habits. In times of stress, some people eat more, while others eat less. The type of food people eat also changes: compared to non-stressed individuals, stressed individuals more often eat unhealthy foods.

Laboratory experiments have shown that stress causes people to make unhealthier food choices. In a typical experiment, participants are exposed to an acute stressor, for instance, they are asked to present themselves before strangers, or to solve a very difficult puzzle within an unrealistically short timeframe. Unknown to the participants, the most important part of the experiment takes place during the breaks, when they are offered food and drinks. Secretly, the researchers observe exactly what the participants eat and drink. They look for differences between those who were exposed to stress prior to the break, and those who were not. And indeed, researchers do typically find differences between these groups. For instance, women who were most sensitive to stress (as shown by an exaggerated cortisol response), also ate more calories in response to stress [1]. In a second experiment, participants who had just performed several difficult tasks in front of a judge, especially those who reported being subjected to chronic stress in daily life, ate more chocolate cake and fewer vegetables compared to non-stressed participants [2].

But how do such laboratory experiments relate to real-life? After all, for most of us, giving presentations is not the most influential stressor in our lives, and real-life situations are much more complex. To investigate how real-life stressors affect food choices, one needs so-called epidemiological studies. In such studies, large groups of people are followed over longer periods of time. At multiple time points, they are asked about their stress levels (including daily hassles, work-related stress, academic stress, etc.) as well as about their eating habits. Consistent with experimental studies, epidemiological studies have shown that, on average, diet quality is lower in people who report more stress (e.g. [3] [4]). However, the effects reported in real-life studies are much smaller compared to the effects reported in the lab: in real life, stress is only one among many factors influencing your food choices.

So exactly how big ís the effect of real-life stress on our real-life food choices? We investigated this in over a hundred thousand people from the North of the Netherlands. We found that exposure to stressful life events, such as the loss of a family member or being the victim of a crime, was associated with poorer diet quality; however, the effects of stress were relatively small. For instance: on average, most people reported having dealt with one stressful life event in the past year, and their average diet quality score (on a scale of 0-48) was 23.9 points. People who reported dealing with two instead of one stressful events had an average diet quality of 23.8 points. For comparison, the difference in diet quality between the average man (22.5 points) and the average woman (24.9 points) in our study was 27 times bigger [5].

To summarize, diet quality deteriorates in times of stress. However, in real life situations, with a multitude of other factors determining what, where and when we eat, the effect of stress alone is very small.

Do you want to learn more about brain changes underlying the effect of stress on food choices? Check out this blog: https://newbrainnutrition.com/stress-and-nutrition-hungry-brain/ by Simone Demmel.

REFERENCES:
[1] Epel, E, Lapidus, R & McEwen, B, Brownell, K (2001). Stress may add bite to appetite in women: a laboratory study of stress-induced cortisol and eating behavior. Psychoneuroendocrinology, 26(1), 37-49

[2] Tryon, MS, DeCant, R, Laugero, KD (2013). Having your cake and eating it too: a habit of comfort food may link chronic social stress exposure and acute stress-induced cortisol hyperresponsiveness. Physiology and behavior, 114-115, 32-37

[3] Mikolajcyk, RT, Al Ansari, W & Maxwell, AE (2009). Food consumption frequency and perceived stress and depressive symptoms among students in three European countries. Nutrition Journal, 8(1),1-8

[4] O’Connor, D, Jones, F, Conner, M, McMillan, B, Ferguson, E (2008). Effects of daily hassles and eating style on eating behavior. Health Psychology, 27(1 supplement).

[5] Schweren et al., in preparation

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Children with ADHD who keep taking micronutrients over one year are mostly in remission in their symptoms with no side effects

The results from a University of Canterbury (UC) study into the longer term effects of micronutrients on ADHD symptoms in children was recently published in the Journal of Child and Adolescent Psychopharmacology.  

This study was led by Dr Kathryn Darling at the Mental Health and Nutrition Lab in Christchurch (under the supervision of Eat2BeNice Scientist Julia Rucklidge) and looked at the long-term effects of a broad-spectrum micronutrient (vitamins and minerals) in attention-deficit/hyperactivity disorder (ADHD) treatment.

Eighty-four of the 93 children who entered a 10-week randomised controlled trial (micronutrients versus placebo), followed by a 10 week phase of all children taking micronutrients, then completed follow-up assessments after 12 months. This allowed us to gather valuable information about what happens when people choose to stay on or come off the micronutrient treatment.

The study showed that children who benefit in the short term from taking a broad-spectrum vitamin/mineral formula maintain those benefits or continue to improve when they keep taking it longer term, without side effects.

Continued micronutrient treatment was associated with improvements in ADHD symptoms which were similar to, or greater than, those associated with stimulant medication. Unlike stimulant medications, micronutrients were associated with improvements, rather than worsening, in mood and anxiety. This indicates that micronutrients can be a serious treatment option for those who choose not to take medications. Micronutrients may be especially helpful for children with ADHD who also have difficulties with mood or anxiety.

Other key findings from this research:

  • Those who continued to take micronutrients did not have any ongoing side effects.
  • Children who continued to take micronutrients and children who changed to medications (like methylphenidate/Ritalin/Concerta) either stayed well or continued to show improvement in ADHD symptoms at 12-month follow-up assessment, while those who stopped treatment altogether did not.
  • Children who switched from micronutrients to medications like methylphenidate/Ritalin were more likely to have problems with mood or anxiety at the 12-month follow-up assessment, which were worse than at the end of the micronutrient trial. After the end of the trial, mood and anxiety symptoms had generally continued to improve for the children who stayed on micronutrients, and mostly stayed the same for those who stopped treatment.
  • The most common reasons people stopped taking micronutrients were the cost and number of pills to swallow.
  • Based on dominant treatment, more of those who stayed on trial micronutrients (84%) were identified as “Much” or “Very Much” improved overall relative to baseline functioning, compared to 50% of those who switched to psychiatric medications and only 21% of those who discontinued treatment. Fifteen (79%) of those still taking micronutrients, 8 (42%) of those using medications, and 7 (23%) of those who discontinued treatment were considered in remission based on parent-reported ADHD. Those who stayed on micronutrients were more likely to have failed medication treatment in the past.

It is important to note that these findings are reporting on group averages, so the effect of micronutrients or other treatments for any specific child may have been different. People do respond differently to any form of treatment – perhaps they benefited across all areas of functioning or perhaps had no benefit at all.

This study is limited due to its naturalistic observational status but allows us to evaluate effectiveness in the real world. No funds were received from the manufacturer of the micronutrients.

If you want to know more about the micronutrients we studied, email mentalhealthnutrition@canterbury.ac.nz

 

Reference:

Darling, K. A., Eggleston, M. J., Retallick-Brown, H., & Rucklidge, J. J. (2019). Mineral-Vitamin Treatment Associated with Remission in Attention-Deficit/Hyperactivity Disorder Symptoms and Related Problems: 1-Year Naturalistic Outcomes of a 10-Week Randomized Placebo-Controlled Trial. Journal of child and adolescent psychopharmacology.

https://doi.org/10.1089/cap.2019.0036

 

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Meet Tim: he is an 8-year-old boy, living in the Netherlands with his parents and younger sister. A couple of years ago, Tim was diagnosed with Attention Deficit Hyperactivity/Impulsivity Disorder (ADHD). His psychologist recommended to participate in the TRACE study: this study examines the short- and long term effects of dietary treatments in children with ADHD. In addition, the TRACE-BIOME study examines the underlying mechanisms of a dietary treatment. For this, we collect blood, stool, and saliva samples and we perform a fMRI. These measurements might, among other things, shed light on the role of the brain-gut-axis.

But what’s it like to participate in a scientific study? First of all, Tim was allocated to one of the two TRACE dietary treatments: an elimination diet or a healthy diet. Tim was allocated to the elimination diet. If we want to know if this diet is effective for Tim, we have to do a lot of different assessments (Figure 1).

Figure 1: assessments TRACE study

 

 

           

 

 

 

 


Before the baseline, 5 week and 1-year assessments, a couple of measurements already take place:

  • Tim wears an Actigraph one week before the assessment, which measures motor activity and sleep-wake rhythm;
  • Parents collect a stool sample from Tim in which his microbiota can be assessed;
  • Parents and teachers fill out different questionnaires about Tim’s behavior, but also about, for example, parenting styles;
  • Parents keep track of a food diary: what does Tim eat during two weekdays and one weekend day?

Before starting the elimination diet, Tim’s parents have a consult with one of the TRACE dieticians, so that they can prepare changing the diet of Tim. Then, it is time for the baseline assessment. Tim and his mother meet the researcher at the hospital for the blood venipuncture. He also has to chew on a cotton pad to collect a saliva sample. After this, they walk to Karakter which is a center for Child and Adolescent Psychiatry. The researcher measures his weight, length, blood pressure and heart rate. Next, Tim has to perform a task on the laptop which he really likes! This task assesses cognitive functions such as sustained attention, working memory, and cognitive flexibility. After the computer task, there is time for a break. Next, they start with behavioral observation. In this task, Tim first plays with his mother and then with the researchers. The different tasks try to elicit ADHD symptoms and emotion (dys)regulation behavior. Finally, the MRI researcher takes Tim and his mother to the fMRI scanner in which he has to do two different tasks. All in all, the assessment takes about 4 hours.

After 5 weeks of the diet, it is time for the second assessment which is the same as the baseline assessment. The researcher has calculated, based on the parent and teacher questionnaires, if there is a significant response to the diet. Tim shows a 40% reduction of ADHD symptoms, which is a significant response! Therefore, they continue the diet. After 4 and 8 months of the diet, his parents receive some online questionnaires. Finally, after one year they are invited for the final assessment, which is again the same as the baseline assessment (without the fMRI).

The following movie explains the assessments described above, in Dutch: 

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Superfoods

Chia Who? – The Superfood Trend
I have a green smoothie every morning with chia seeds and acai berries, you should try it too! I feel so fit and healthy!” Have you ever heard this or a similar sentence in your life? In recent years, more and more people have been talking about superfoods. There are many new restaurants with superfoods on the menu and a sharp increase in coverage of superfoods in beauty, health and nutrition magazines. Increasing concerns about health and aging society appear to be an important driver of the superfood trend in Europe, as a rapid rise in new products enters a dynamic and growing market. Every season new products are introduced and advertised as superfoods. The United States are in first place at importing goods labeled as superfood, Germany ranks second (4).

But what are superfoods exactly and what makes it so “super” and different from functional food?
Superfood can be defined as food that is considered particularly nutritious and energy-dense. Foods that fall into this category include chia seeds, acai berries, blueberries, beetroot, soy, pomegranates, green tea, goji berries, coconut oil, salmon, dark chocolate, cocoa and kale (2). Some of these superfoods, like chia seeds or goji berries, have turned into established products that can be obtained in almost every supermarket or even in discounters. Among the superfoods, goji is the leading superfood product. “Goji” is the generic name for different plant species from the genus lycium (2). However, superfood is neither a registered trademark nor a legally protected term. All definitions have in common that they describe superfoods as a food that has a high nutrient density. This means a comparatively high amount of e.g. proteins, vitamins, minerals, polyunsaturated fatty acids, phytochemicals, and antioxidants. The problem is, however, that many of these products are extremely damaged by pollutants that can have even negative effects on our health. Also, they usually have long transport routes behind them, which is not only bad for the climate but can also decrease the nutrient density.

So what’s the conclusion and the recommendation?
Overall, superfoods are a good thing, but superfoods should not emphasize some single representatives or nutrients, because the variety and complexity of the entire nutrition is important for a healthy lifestyle. In addition, it depends on the lifestyle in general, so a lot of exercise, sufficient sleep, social contacts and a positive attitude to your life are key (3). A healthy diet with a lot of fruits and vegetables has not only positive effects on your physical health; it also has a significant influence on your psychological well-being. Therefore it is not only worthwhile for your body but also for the mind to significantly increase your personal fruit and vegetable consumption. It is crucial that your diet includes essential vitamins and nutrients which can help in relieving symptoms of depression, mood disorders, and other mental illnesses (6).

For some, lifestyle might be considered more important than sustainability at this point, because many local products like blackberries, linseeds, or peppers offer the same high vitamin content as superfoods, but do not have the wonderful image of superfood (1). So if you want to buy superfoods like goji berries or chia seeds, it makes sense to buy certified organic products. They are manufactured without the use of chemical pesticides and fertilizers. The Fairtrade seal is also a guarantee of more sustainability for products from distant countries. And don’t forget that agriculture in Germany and Europe also has many local “superfoods” to offer. Flax seeds, for example, are a real good alternative to chia seeds because they have similar “slime forming” properties.

Certainly, the trendy superfood products have many beneficial properties for our health. But the native fields provide all the vitamins that you need, too, often at a much lower price. For a healthy diet, berries (for example) are not required. Those who eat a varied and balanced diet can do it also with local fruits and vegetables. It is worthwhile in many ways to look for fresh, seasonal and organically grown fruits and vegetables on the market! And anyway – self harvested “superfood” tastes the best! (5).

REFERENCES:

  1. Ortner, J. (2018). In aller Munde – eine soziodramatische Betrachtung der Ernährung. Wiesbanden: Springer
  2. Wetters, S., Horn, T., Nick, P. (2018) Goji Who? Morphological and DNA Based Authentication of a “Superfood”.  Plant Sci.9:1859. doi: 10.3389/fpls.2018.01859
  3. Feichtinger, J. (2019). Heimisches Superfood: regional und nährstoffreich. In: Ernährung & Medizin 34(03):147-155
  4. Sikka, T. (2017). Contemporary Superfood Cults: Nutritionism, Neoliberalism, and Gender. In: Cargill, K. (2017). Food Cults. How Fads, Dogma, and Doctrine influence Diet. Maryland: Rowman & Littlefield
  5. https://www.oekolandbau.de/bio-im-alltag/einkaufen-und-kochen/trends-und-tests/superfoods/
  6. https://www.zentrum-der-gesundheit.de/news/gesunde-ernaehrung-psychisches-wohlbefinden-170204017.html
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To investigate whether nutrition plays a role in inhibitory control and executive functioning early in life, we collected data on behavior using different tasks (see previous blog). To perform these tasks, we choose to visit the children at home with the aim 1) to burden the families less, and 2) to test the children in their home environments where they are probably more at ease. Testing 3-year-old children is very fun a

October 1

nd can also be challenging at the same time. I will share some anecdotes and experiences of my data collection as inspiration for others testing young children.

Attention
Some tasks had lengthy instructions and required the child to perform several practice trials, resulting in the child losing his/her attention. The sequence of the tasks was constructed in such a way that the child’s attention was maintained as long as possible. For example, the tasks that required more attention, focus and instructions were performed first.

Sometimes children said to be not in the mood to play anymore, or that they didn’t know what to do despite passing the practice trials. Repeating the rules is not possible, because it means that some children will receive more instructions than other children. I solved this problem by telling the child that he/she would be rewarded if he/she finished the task. Rewards could be a fun game they can play next, or some snacks that the parents agreed to giving.

Parents
Parents sometimes tended to help their child. To prevent this, it is very important to instruct the parents not to help their child. Another way to prevent the parent from helping is to keep them busy by having them fill in a questionnaire, or to turn to the child and say things like: “are you a bit nervous because Mum is looking?” Sentences as these work very well, as you are not telling the parent directly what to do, but they understand the hint immediately.

Siblings
Toddlers often have siblings; sometimes younger siblings and sometimes older siblings. If possible, parents are asked to arrange the situation this way that the siblings are not at home and/or are asleep. When not possible, an assistant accompanying the experimenter can take care of the siblings, for example by taking the sibling outside and play soccer in the neighborhood. Everything for science!

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Have you ever done your weekly grocery shopping and ended up with more than actually written on your grocery list?
Everybody has at least once experienced how it is to buy food in a supermarket with hunger and buy much more than planned. The widely known recommendation: Never go grocery shopping when you are hungry!!!

But is it only a myth or is there a grain of truth in that advice?
What exactly is the issue with going grocery shopping when you are hungry? If you do you probably buy more food than you need and planned to buy. Additionally, unhealthy food might be much more attractive for you than healthy food. The consequence: you have more food at home, so you might eat more and unhealthier. Imagine you are hungry and are coming home from work after a stressful day and now you get to choose between a frozen pizza and a healthy meal that has not been prepared yet – What would you choose? In that situation, I think I would definitely choose the frozen pizza.

High-calorie food and unhealthy food are associated with obesity. Obesity research found a moderate relationship between obesity and emotional disorders like depressive disorder and anxiety disorder (1). Thus, having fast food frequently might not only affect your physical, but also your mental well-being.

Let’s rewind to grocery shopping, but now consider you are not hungry. You probably would only buy the things that are on your grocery list, and also rather healthy food than an unhealthy one. So now you come home hungry from a stressful day at work and you don’t have the choice between healthy and unhealthy food, and the temptation of the frozen pizza isn’t there. So you would start to prepare your healthy food and thus automatically eat healthier.

Coming back to the question if these scenarios are devised or true, and thus representative for weekly grocery shopping.
Research has shown that impulsivity, obesity, and food buying behavior are related. People with obesity are more impulsive than slim people. Also, impulsive people eat more than less impulsive people. Hunger influences food buying behavior and food consumption, especially of high caloric food. The relationship between impulsivity and buying food might be state dependent: researchers have found that impulsive people bought more calories, especially from snack food, but only when they were feeling hungry. This means that impulsivity and hunger interact in their influence on consumption. Obese people are found to show a preference for energy-dense, high-fat food and eat more of these foods, compared to slim people (2).

So what’s the conclusion?
Yes, hunger influences your grocery shopping, especially in interaction with impulsivity. If you consider yourself an impulsive person, you might be more prone to buying more than intended when you go shopping hungry.

So if you have the chance: only go shopping for groceries when you are full and focused. If you accidentally get into a hungry grocery shopping situation, keep this blog in mind and try to focus on your grocery list.

REFERENCES:
Scott, K. M., Bruffaerts, R., Simon, G. E., Alonso, J., Angermeyer, M., de Girolamo, G., … & Kessler, R. C. (2008). Obesity and mental disorders in the general population: results from the world mental health surveys. International journal of obesity32(1), 192.

Nederkoorn, C., Guerrieri, R., Havermans, R. C., Roefs, A., & Jansen, A. (2009). The interactive effect of hunger and impulsivity on food intake and purchase in a virtual supermarket. International journal of obesity33(8), 905.

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A healthy diet has numerous benefits. But what does a healthy diet consist of? And how do we, researchers, measure diet quality?

What’s considered a healthy diet in one country or culture, may not be regarded as such in another. For instance, low-fat and unsweetened dairy products are regarded as healthy in my country, the Netherlands, but not in many Asian countries where a vast proportion of the population is lactose intolerant. Differences in regional availability of foods further determine dietary habits across, and even within, countries. Fish, for example, is often at the core of a healthy diet in countries surrounded by water such as Japan (48.6 kg/year per person), but not in landlocked countries such as Hungary (5.1 kg/year per person) [1].

Here I will describe six common ways in which researchers may assess diet quality in Western populations.

1. Fruit and Vegetable Consumption

Probably the quickest way to obtain an estimate of an individual’s diet quality is by assessing fruit and vegetable consumption of the individual. Generally speaking, fruits and vegetables are high in healthy nutrients such as vitamins and fibers. Moreover, fruits and vegetables often replace unhealthier options such as energy-dense snacks. Finally, while fruit and vegetable consumption is only one aspect of diet quality, it has been shown to correlate with overall diet quality. Thus, fruit and vegetable consumption can be seen as a fast but crude way to assess diet quality.

2. Total Energy Intake

One could consider calculating total energy intake as an indicator of diet quality. Generally speaking, unhealthy foods are more energy-dense than healthy foods. Therefore, high-calorie diets likely contain more unhealthy foods. Of course, this is not necessarily the case; some foods, for instance avocado, are both energy-dense and nutrient-rich. Moreover, low energy intake may result in nutritional deficits. Therefore, total energy intake is not generally used as an indicator of diet quality.

3. Mediterranean Diet Score

The Mediterranean Diet Score (MDS) measures compliance to a Mediterranean-type diet, consisting of legumes, fruits, vegetables, unrefined cereals, olive oil and fish. Points are subtracted for dairy and meat [2]. The Mediterranean diet was inspired by the eating habits of Greece and Italy, where people seem to live longer and have lower risk of heart disease compared to other Western regions.

4. Western-Type Diet Score

A Western-style diet is a modern dietary pattern, that is sometimes referred to as the Standard American Diet. A Western diet consists of red and processed meats, pre-packaged foods, fried foods, whole-fat dairy products, refined grains, potatoes and sugar-sweetened beverages, among others [3]. Contrary to most diet quality scores, a higher Western diet score indicates a less healthy diet.

5. Healthy Eating Index

The Healthy Eating Index (HEI) measures how well an individual adheres to the key recommendations of the 2015 Dietary Guidelines for Americans. These guidelines are often used by US-based nutrition and health professionals, to help people to consume a healthful and nutritionally adequate diet. A total score is calculated based on nine advised food groups/components (including fruits and vegetables, whole grains, plant proteins), and four components that should be moderated (including salt and saturated fat) [4].

6. Dietary Approaches to Stop Hypertension

The dietary approaches to stop hypertension (DASH) dietary pattern emphasizes fruits, vegetables, low-fat dairy, whole grains, nuts and legumes, and limits saturated fat, cholesterol, red and processed meats, added sugars, and sugar-sweetened beverages. It was originally developed in the US to treat hypertension without medication [5]. Several medical associations and institutions have since incorporated the diet in their clinical guidelines [6]. 

REFERENCES:

[1] Ritchie & Roser (2019). Meat and Seafood Production & Consumption. Published online at OurWorldInData.org. Retrieved from: https://ourworldindata.org/meat-and-seafood-production-consumption on 28 August 2019

[2] Dinu, Pagliai, Casini & Sofi (2018). Mediterranean diet and multiple health outcomes: an umbrella review of observational studies and randomised trials. European Journal of Clinical Nutrition, 72(1), 30-43. doi: 10.1038/ejcn.2017.58

[3] Cordain, Eaton, Sebastian, Mann, Lindeberg, Watkins et al. (2005). Origins and evolution of the Western diet: health implications for the 21st century. American Journal of Clinical Nutrition, 81(2), 341-354. doi: 10.1093/ajcn.81.2.341

[4] US Department of Agriculture, Food and Nutrition Service. Retrieved from https://www.fns.usda.gov/resource/healthy-eating-index-hei on 28 August 2019

[5] Sacks, Svetkey, Vollmer, Appel, Bray, Harsha et al. (2001). Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. The New England Journal of Medicine, 344(1), 3-10. doi: 10.1056/NEJM200101043440101

[6] Chiavaroli, Viguiliouk, Nishi, Mejia, Rahelic, Kahleova et al. (2019). DASH Dietary pattern and cardiometabolic outcomes: an umbrella review of systematic reviews and meta-analyses. Nutrients, 11(2), 338. doi: 10.3390/nu11020338

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