In every classroom, approximately two children are diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). They struggle with attention problems and hyperactive and impulsive behavior. This has negative consequences for these children. For example, they can have difficulties learning, it puts them at risk for other psychiatric problems, and it can cause parent-child relationship problems. Therefore, children with ADHD do need some sort of treatment for optimizing the quality of their lives.

After psycho-education to the child, parents and teacher, medication is often the first choice of treatment because it is evidence-based. However, there is a growing group of parents that do not wish to medicate their child. They are concerned about the side and long-term effects. Thus, these parents seek other treatment. That is where they get stuck: which other effective treatments are available?

In order to develop new treatments, there is a growing field of research focusing on risk factors for ADHD symptoms. One of these risk factors that has been studies increasingly is nutrition. Nutrition plays a role in physical well-being, but could also play a role in psychological well-being and cognitive functioning. Consequently, dietary treatments could be an alternative treatment for children with ADHD. There is a long history of research in nutrition, but there is not enough evidence yet about the cost-effectiveness to implement dietary treatments in clinical health care.

So far, studies examining the effectiveness of a so-called elimination diet showed the strongest effects (1). The aim of an elimination diet is to find out which products trigger ADHD symptoms. However, results of these studies are inconclusive because of several limitations. First, outcome measurements used in these studies were not objective. Second, studies suffered from a sample bias towards highly motivated and educated parents. Third, underlying mechanisms are still unknown. Fourth, long-term effects are unknown. Moreover, it is unknown if an elimination diet is more effective in reducing ADHD symptoms than a healthy diet based on the World Health Organization (WHO) guidelines (2).

We thought: can we take into account these limitations ánd examine the effectiveness of two dietary treatments? This resulted in the TRACE study: ‘Treatment of ADHD with Care as usual versus an Elimination diet’ (TRACE) study. This is the first study to determine the short- and long-term effectiveness and cost-effectiveness of two dietary treatments as initial addition to care as usual as a treatment trajectory for children with ADHD. We will substantially improve upon previous studies by implementing the intervention in non-commercial mental health centers, including blinded and objective measurements, and comparing two dietary treatments with care as usual. Also, understanding the biological effects could inform clinicians to potential markers and targets for preventative or individualized treatment. For this reason, we also examine the underlying biological mechanisms (e.g. mechanisms in the gut and brain) of dietary treatments (TRACE-BIOME and TRACE-MRI studies). We collect blood, stool and saliva samples.

The TRACE study is a two-arm randomized control trial: participants are randomized to either an elimination diet or a healthy diet. The comparator arm includes children who are being treated with care as usual. Currently, we included in each dietary treatment arm about half of the targeted participants (N=81 in each dietary group). In the care as usual group, we included about one-third of the targeted participants (N=60). We hope to finish inclusion around January 2020.

I am really looking forward to the results and hope to share this with you in a couple of years! If you have any questions, feel free to contact us via trace@karakter.com

REFERENCES
(1) Nigg, J. T., Lewis, K., Edinger, T., & Falk, M. (2012). Meta-analysis of attention- deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 86-97. https://doi.org/10.1016/j.jaac.2011. 10.015 .
Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321798/

(2) Izquierdo Pulido, M. L., Ríos Hernández, A., Farran, A., & Alda, J. Á. (2015). The role of diet and physical activity in children and adolescents with ADHD. Recent Advances in Pharmaceutical Sciences V, 2015, Research Signpost. Chapter 4, p. 51-64.
Link: http://diposit.ub.edu/dspace/bitstream/2445/67543/1/T_1444299316Munozv%204.pdf

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Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with an estimated prevalence rate of 5.3% among children and of about 2.5% among adults. It is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity, being associated with significant impairment of social, academic, and occupational functioning across the lifespan.

However, despite many efforts, the exact etiology of ADHD still remains unknown and data about modificable risk and protective factors are largely lacking. Recent evidence has suggested an association between inflammation, immunological disturbances and ADHD. Supporting this idea, an increased incidence of immune-mediated disorders (e.g. asthma, allergic rhinitis, atopic dermatitis, allergic conjunctivitis, psoriasis, thyrotoxicosis or type 1 diabetes) accompanied by elevated serum/plasma and cerebrospinal levels of inflammatory markers (especially interleukin (IL)-6) or auto-antibody levels (e.g. antibasal ganglia antibodies, antibodies against the dopamine transporter) have been found in these patients.

Importantly, recent studies have shown the gut flora as an important immunoregulator (1-3) and it is hypothesized that an imbalance in the gut microbiota (dysbiosis) may have a negative effect on cerebral development and behavior (4). About 95% of all circulating serotonin, dopamine or noradrenaline precursors are produced by our gut microbiota, being this ‘enteric nervous system’ bidirectional connected to the central nervous system through hormonal or immune/inflammatory pathways.

In line with this, recent findings suggest that some aliments as probiotics can not only revert dysbiosis, but also modulate brain neurodevelopment, activity and improve cognition, mood and behavior due to their immunoregulatory and anti-inflammatory properties (5-7).

Therefore, understanding the microbiota and how the gut connects to the brain would be important both for the better comprehension of the biological bases that underlie some psychiatric disorders such as ADHD, as for the future development of new evidenced-based drugs for these conditions.

This was co-authored by Josep Antoni Ramos-Quiroga, MD PhD psychiatrist and Head of Department of Psychiatry at Hospital Universitari Vall d’Hebron in Barcelona, Spain. He is also professor at Universitat Autònoma de Barcelona.

REFERENCES:

1. Felix KM, Tahsin S, Wu HJ. Host-microbiota interplay in mediating immune disorders. Ann N Y Acad Sci. 2018; 1417(1):57-70.

2. Yadav SK, Boppana S, Ito N, Mindur JE, Mathay MT, Patel A, et al. Gut dysbiosis breaks immunological tolerance toward the central nervous system during young adulthood. Proc Natl Acad Sci U S A.2017; 114(44): E9318-27.

3. Mandl T, Marsal J, Olsson P, Ohlsson B, Andreasson K. Severe intestinal dysbiosis is prevalent in primary Sjögren’s syndrome and is associated with systemic disease activity. Arthritis Res Ther.2017;19(1):237.

4. Rogers GB, Keating DJ, Young RL, Wong ML, Licinio J, Wesselingh S. From gut dysbiosis to altered brain function and mental illness: mechanisms and pathways. Mol Psychiatry. 2016; 21(6):738-48.

5. Slykerman RF, Kang J, Van Zyl N, Barthow C, Wickens K, Stanley T, et al. Effect of early probiotic supplementation on childhood cognition, behavior and mood. A randomized, placebo-controlled trial. Acta Paediatr.2018; 107(12):2172-78.

6. Kane L, Kinzel J. The effects of probiotics on mood and emotion. JAAPA. 2018; 31(5):1-3.

7. Mayer EA. Gut feelings: the emerging biology of gut-brain communication. Nat Rev Neurosci.2011;12(8):453-66

 

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The food choices we make, how much we exercise and the amount of body fat we have affects our health already at a young age. Although seemingly healthy, our metabolism might tell a different story. This can already be seen at a young age.

The Estonian Children Personality Behaviour and Health Study (ECPBHS) started 20 years ago in 1998 and has since measured the participants’ body composition and assessed their metabolic abnormalities, such as insulin resistance and metabolic syndrome, at ages 15, 18, 25 and 33 years.

Insulin resistance is a state in which the body does not respond to normal levels of insulin efficiently, eventually causing a rise in blood sugar levels. It has been proposed that insulin resistance has a role in the development of several metabolic abnormalities what we know as metabolic syndrome1. These metabolic abnormalities include a large waistline (abdominal obesity), high levels of certain types of fat in the blood called triglycerides, a low level of HDL cholesterol, high blood pressure or usage of blood pressure medication and elevated fasting blood sugar levels or type 2 diabetes diagnosis2.

We have found that already at age 25, individuals who consumed more than 300 milligrams of cholesterol per day and had more than 4 hours of screen time were at higher risk of components of metabolic syndrome3. Insulin resistance was associated with male gender3,4, overweight and obesity, low physical activity levels and the consumption of lipids above the recommended daily energy intake*4. Individuals who consumed carbohydrates below the recommended daily energy intake*, were less likely to be insulin resistant. Already at age 25, insulin resistant individuals had higher serum cholesterol, lower HDL cholesterol, and higher triglyceride levels, fasting blood sugar and insulin levels. People who were overweight also had 4 times higher odds of insulin resistance and being obese increased the odds 12 times if compared to normal weight individuals4. From 15 to 25 years the occurrence of components of metabolic syndrome increased rapidly. At age 15 years 18% of participants had one or more metabolic abnormality and by age 25 years the number had doubled, whereas 5% already had metabolic syndrome.3 Individuals who were insulin resistant were more likely to have metabolic syndrome.4

Insulin resistance and the metabolic syndrome are risk factors for type 2 diabetes and cardiovascular disease later in life1. As we observed, one fifth of the adolescents already have at least one metabolic abnormality and the number of components of metabolic syndrome increases from adolescence to young adulthood. That is why it is important that healthy lifestyle habits should be introduced and encouraged already in early childhood. Although young people may seem to be healthy, the first signs of developing metabolic abnormalities may already be there.

*According to the Estonian nutrition and physical activity recommendations (2015), the recommended consumption of macronutrients from daily energy intake (E%) is as following: proteins 10–20%, lipids 25–35%, carbohydrates 50–60%5.

Written by:
Urmeli Joost, MSc is a PhD student at the Institute of Family Medicine and Public Health, University of Tartu, Estonia. Her main focus of research is the genetic, environmental and behavioural factors in obesity, dyslipidemia and glucose metabolism.

Inga Villa, MD, PhD is a Lecturer in Health Promotion at the Institute of Family Medicine and Public Health, University of Tartu, Estonia. Her main focus of research is nutrition, physical activity and sociocultural factors on health status and body composition.

REFERENCES
1. Xu, H., Li, X., Adams, H., Kubena, K. & Guo, S. Etiology of Metabolic Syndrome and Dietary Intervention. Int J Mol Sci 20, (2018).

2. Alberti, K. G. M. M. et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 120, 1640–1645 (2009).

3. Taimur, T. Metaboolse sündroomi komponentide levimus ja seosed toitumisega noorukieast täiskasvanueani. Tartu: Tartu Ülikooli peremeditsiini ja rahvatervishoiu instituut; 2018.

4. Joost U. Insuliinresistentsuse seosed elustiiliharjumustega noortel täiskasvanutel Eestis [masters thesis]. Tartu: Tartu Ülikooli tervishoiu instituut; 2015.

5. Pitsi, et al. Eesti toitumis- ja liikumissoovitused 2015. Tervise Arengu Instituut. Tallinn, 2017.

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Our body is colonized by trillions of microorganisms that are important for vital processes. Gut microbiota are the microorganisms living in the intestinal gut and play an essential role in digestion, vitamin synthesis and metabolism, among others. The mouth and the large intestine contain the vast majority of gut microbiota whether the stomach only contains few thousands of microorganisms, especially due to the acidity of its fluids. Microbiota composition is constantly changing, affecting the well-being and health of the individual.

Each individual has a unique microbiota composition, and it depends on several factors including diet, diseases, medication and also the genetics of the individual (host) (Figure). Some medicines, especially antibiotics, reduce bacterial diversity. Strong and broad spectrum antibiotics can have longer effects on gut microbiota, some of them up to several years. Genetic variation of an individual also affects the microbiota composition, and the abundance of certain microorganisms is partly genetically determined by the host.

The main contributor to gut microbiota diversity is diet, accounting for 57% of variation. Several studies have demonstrated that diet’s composition has a direct impact on gut microbiota. For example, an study performed on mice showed that “Western diet” (high-fat and sugar diet), alters the composition of microbiota in just one day! On the other hand, vegetarian and calorie restricted diet can also have an effect on gut microbiota composition.

Prebiotics and probiotics are diet strategies more used to control and reestablish the gut microbiota and improve the individual’s health. Probiotics are non-pathogenic microorganisms used as food ingredients (e.g. lactobacillus present in yoghurt) and prebiotics are indigestible food material (e.g. fibers in raw garlic, asparagus and onions), which are nutrients to increase the growth of beneficial microorganisms.

In the last years the new term psychobiotics has been introduced to define live bacteria with beneficial effects on mental health. Psychobiotics are of particular interest for improving the symptomatology of psychiatric disorders and recent preclinical trials have show promising results, particularly in stress, anxiety and depression.

Overall, these approaches are appealing because they can be introduced in food and drink and therefore provide a relatively non-invasive method of manipulating the microbiota.

AUTHORS:
Judit Cabana-Domínguez and Noèlia Fernàndez-Castillo

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Every child knows: sugar is bad for the teeth. Nutrition with a high amount of sugar does not only put you at a risk of dental cavities but also affects your physical and mental health, mood and memory.

Sick? Current researches associate sugar consumption with overweight and obesity, which increases the risk of various subsequent illnesses: diabetes type 2, cardiovascular diseases (risk for stroke and heart attack), dementia and cancer. (1)

Sad? In a study on patients with diabetes type 2 the level of blood sugar was manipulated. When the blood glucose was elevated (> 16,5 mmol/l) participants had a reduced energetic arousal and felt more sadness and anxiety (2).

Stupid? In a study on healthy adults memory skills and blood sugar levels were measured. Participants with higher blood sugar levels showed worse memory performance than adults with lower glucose levels. This difference was mediated by structural changes in the brain (3). Another study found that high blood sugar levels within the normal range (> 6.1 mmol) were associated with 6-10% loss in brain volume. The loss effected hippocampus and amygdala -areas that are important for learning, memory and cognitive skills (4).

The WHO recommends the intake of less than 10% or even better less than 5% free sugars of the daily total energy intake. For an adult that means less than 25 grams (6 teaspoons) per day (5). The problem is: there is a high amount of sugar in products where we don’t expect it.

So here are some tips to avoid sugar:
1. Pay attention to the ingredients list: There are many names to cover the total amount of contained sugar in products. Everything ending with “-ose” or “syrup” is sugar. The position on the list indicates the relative amount of a compound, so producers often mix different sugars in order to “hide” them at the end of the ingredients list. In “light” products the missing fat is often replaced by sugar. Better base your nutrition on staple foods like whole-grain food, fruits and vegetables to avoid hunger pangs as a response to changes in blood sugar level.
2. Avoid ready-made products such as pizza, sauces, soups or ketchup. You might be surprised how much sugar they contain! Also, many cereals and yoghurts contain high amounts of sugar. Prepare it yourself: Use unsweetened yoghurt and add your favourite fruits.
3. Step by step: Reduce your sugar intake slowly to be successful in the long term. For example, day by day put a bit less sugar into your coffee to get used to it.
4. Save on baking sugar: Just use less than stated in the recipe – it tastes just as good.
5. Replace sugary drinks with water or unsweetened teas. Add lemon, mint or pieces of fruit to your water.
6. Make it something special: If you don´t buy sweets you will be less tempted by them. It may be a good rule to eat cake and cookies only on special days or with friends.
7. Size does count: A small treat, when eaten attentive, will satisfy you better than the whole chocolate bar you consume while being absorbed by reading the newspaper, watching a movie, or driving your car.
8. Avoid sugar substitutes: Honey, agave syrup and fruit extract, etc have the same effects as refined sugars. It’s healthier to get used to less sweetness.
9. Experiment with spices: Instead of sugar, spices such as cinnamon, vanilla or cardamom can enhance flavor.
10. Eat fruits: Satisfy your sweet tooth with fruits instead of sugar.
Get to know the natural taste of your food 😊

Shortened version:
1. Pay attention to the ingredients list: Everything ending with “-ose” or “syrup” is sugar. In “light” products the missing fat is often replaced by sugar.
2. Avoid ready-made products such as pizza, sauces, soups or ketchup. Also, some cereals and yoghurts contain a relatively high amount of sugar.
3. Save on baking sugar: just use less than stated in the recipe – it tastes just as good.
4. Replace sugary drinks with water or unsweetened teas. Add lemon, mint or fruits to your water.
5. Avoid sugar substitutes: Honey, agave syrup and fruit extract, etc have the same effects as refined sugars. It’s healthier to get used to less sugar.
Get to know the natural taste of your food 😊

REFERENCES:
(1) Stanhope K. L. (2016). Sugar consumption, metabolic disease and obesity: The state of the controversy. Crit Rev Clin Lab Sci, 53(1): 52-67. doi: 10.3109/10408363.2015.1084990.

(2) Sommerfield, A. J., Deary I. J. & Frier, B. M. (2004). Acute Hyperglycemia Alters Mood State and Impairs Cognitive Performance in People With Type 2 Diabetes. Diabetes Care, 27: 2335–2340.
doi: 10.2337/diacare.27.10.2335.

(3) Kerti, L., Witte, A. V., Winkler, A., Grittner, U., Rujescu, D. & Flöel, A. (2013). Higher glucose levels associated with lower memory and reduced hippocampal microstructure. Neurology, 81 (20), 1746- 1752.
doi: 10.1212/01.wnl.0000435561.00234.ee.

(4) Cherbuin, N., Sachdev, P. &Anstey, K. J. (2912). Higher normal fasting plasma glucose is associated with hippocampal atrophy: The PATH Study. Neurology, 79 (10): 1019- 1026.
doi: 10.1212/WNL.0b013e31826846de.

(5) WHO Library Cataloguing-in-Publication Data (2015). Guideline: Sugar intake for adults and children. World Health Organization.
Retrieved from: http://apps.who.int/iris/bitstream/handle/10665/149782/9789241549028_eng.pdf;jsessionid=3F96BB43E2B34C12341B1EB60F035587?sequence=1.

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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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Whenever I ask my patients, if they are eating their “5 a day”, the immediate answer is “Yes, sure”. However, sometimes I´m not sure if their “Yes, sure” belongs to their real eating behavior or if it is more like wishful thinking. This question applies for a broad range of behavior, like taking the stairs instead of the elevator, having enough sleep, walking the 10.000 steps a day etc.. But how can we be sure what people really do in their everyday life?

The answer is: Ambulatory Assessment

Ambulatory Assessment is the state of the art method for assessing current emotional states, feelings, and behavior in the natural environment of an individual’s everyday life. Equipped with smartphones and accelerometers, it is feasible to track how individuals feel at specific moments, what they are eating across a day and how they physically behave in real time and real life. Electronic e-diaries, provided by an App, prompt individuals whenever an event occur or randomly several times a day. Especially in patient groups with attention deficits, prompting short questionnaires several times a day show better recall than an extensive end-of-day questionnaire.

In the past, food-diaries were based on unhandy and retrospective paper-pencil-questionnaires or computer input. Nowadays, new technological opportunities pave the way to e-food-diaries on smartphones, enabling an immediate and flexible input capability. The design of e-food-diary-apps may be different, i.e., by photos, drop-down-menu, text, or voice records. Important is the documentation of what and how much the participants eat and drink and a database that can be connected to an international or national food code for data analysis.

In the Eat2beNICE research project, we assess food intake every time participants eat or drink by a drop-down-menu that leads from general to very detailed food-items and asks for general meal portions and amounts every time participants eat and drink across the day. If a participant cannot find a particular food-item, he or she has the opportunity to enter a free text message or to record a voice message. If participants forget to enter some foods and drinks across the day, they will receive a reminder in the evening to add forgotten items. This procedure enables very accurate tracking of participant’s food intake in our study.

To sum up, thanks to modern technology we can now accurately measure what a person feels, does and eats throughout the day. Of course, the design of an e-food-diary on the smartphone depends on the projects’- and samples’ requirements. Overall, it has to be easy to use, easy to implement in daily life and to be fun for the participants to obtain a high level of compliance and a high-quality database.

REFERENCES:
Ebner-Priemer, U. W., & Trull, T. J. (2009). Ambulatory Assessment: An Innovative and Promising Approach for Clinical Psychology. European Psychologist, 14, 109–119. https://doi.org/10.1027/1016-9040.14.2.109.

Engel, S. G., Crosby, Ross, Thomas, G., Bond, D., Lavender, J. M., Mason, T., . . . Wonderlich, Stephen. (2016). Ecological Momentary Assessment in Eating Disorder and Obesity Research: a Review of the Recent Literature. Current Psychiatry Reports, 18, 37. https://doi.org/10.1007/s11920-016-0672-7.

Fuller, N. R., Fong, M., Gerofi, J., Ferkh, F., Leung, C., Leung, L., . . . Caterson, I. D. (2017). Comparison of an electronic versus traditional food diary for assessing dietary intake-A validation study. Obesity Research & Clinical Practice, 11, 647–654. https://doi.org/10.1016/j.orcp.2017.04.001.

Smyth, J., Wonderlich, S., Crosby, R., Miltenberger, R., Mitchell, J., & Rorty, M. (2001). The use of ecological momentary assessment approaches in eating disorder research. The International Journal of Eating Disorders, 30, 83–95.

Stein, K. F., & Corte, C. M. (2003). Ecologic momentary assessment of eating-disordered behaviors. The International Journal of Eating Disorders, 34, 349–360. https://doi.org/10.1002/eat.10194.

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The more diverse we eat, the more diverse our gut microbiome (i.e., the composition of trillions of microbes in our intestine) will become. Sounds reasonable, right? But – why is that a good thing?

Well, research has shown that a diverse gut microbiome is less susceptible to diseases, such as the well-known western lifestyle associated diseases like diabetes or Crohn’s disease (1). This might be because one’s microbiome and one’s immune system are closely linked. A healthy and diverse microbiome thus might support proper functioning of our immune system and help keeping us healthy.

Eating a variety of different food items also enhances the odds that your body gets all the nutrients like vitamins or minerals it needs for proper functioning. This can have an effect on our well-being as well as on our physical appearance, like shiny hair, strong fingernails and healthy-looking skin.

Besides, research suggests that the more diverse we eat, the better our cognitive abilities might be at older age (see my blog on this topic here:
http://newbrainnutrition.com/four-easy-rules-for-healthy-eating-and-lifestyle/)! Well, how about that!? Research supports the notion that our gut and our brain are more closely linked than we would have assumed. This would mean that our food choices can actually have an effect on our mental health. Great, right?

So let’s have a look at a few simple tips with which you can easily enhance your dietary diversity, and can have fun along the way, too!

1. Add seeds and nuts to your meals
2. Eat a set menu
3. Grow your own fresh herbs
4. Enlarge the variety of what you drink
5. Try alternatives to your staple foods
6. Try new dishes, restaurants and cuisines
7. Join a food cooperative
8. Distribute your homemade meals across different days
9. Experiment with seasonings
10. Try smoothies and soups
11. Share your meals
And the golden rule you should keep in mind:
12. Avoid antibiotics

Add seeds and nuts to your meals
By keeping a variety of seeds and nuts at home, you can easily add them to your meals. If you tend to overeat on nuts (and believe me, many people do), make sure to buy unsalted ones, and simply sprinkle them on top of your muesli, salad or sandwich. Nuts (like peanuts, walnuts, hazelnuts) and seeds (like sesame or flaxseed) are a great source of very healthy fats, important vitamins like B-vitamins and vitamin E, and they contain fibres, which our gut simply loves!

Eat a set menu
Yes, you heard me. This is my advice to select a sequence of dishes, instead of only one.
This will definitely result in a larger variety of what you eat. Of course, you should be aware of the overall amount of food – listen to your gut feeling! And I’m serious, this also includes dessert! If you have a little soup, a colorful salad, a light main course and a small treat, you’ve supplied your body with a variety of different nutrients it needs to stay healthy. My extra tip: Keep in mind to include your ‘five a day’ to make sure you eat enough fruit and especially enough vegetables.

Grow your own fresh herbs
Do you notice that food pictures look more appealing when the food is sprinkled with fresh herbs? It will also appeal to your gut! Adding one or two fresh herbs to a dish will give it that little extra twist that it deserves. All it takes is a plant pot on your window sill. Some herbs can be harvested throughout the whole year, and for even more diversity, you can experiment with different plants as you go.

Enlarge the variety of what you drink
Tea or coffee? Both, please! When we think of nutritional diversity, let’s not only consider solid food. Imagine having your coffee and a glass of orange juice (or even a multivitamin drink) with your breakfast. How about some green or black tea as the day goes by? Or an apple spritzer? Herbal teas also offer a great range of different ingredients, and can be soothing in the evening. Just keep in mind that if you taste a few different lemonades, you well might enhance your variety of drinks, but you will consume a lot of sugar, too. The world health organization recommends that maximally 10% of your energy should come from sugar (2), which should be considered when ordering a drink.

Try alternatives to your staple foods
Are you a muesli guy? Or more of a bread person? Do you prefer pasta as your everyday dish or is your menu dominated by rice? Most of us tend to eat the same basic food items every day. But even here is the chance to enhance diversity: Instead of rice, try couscous, amaranth or millet. Buy a different type of bread every time you go to the bakery. Muesli offers a great chance of variety, you can add honey, yoghurt, marmalade, berries, spices… Talk to your friends to get more ideas.

Try new dishes, restaurants and cuisines
Every cuisine has its own flavours, specific components, and style. So why not raiding cook books and food blogs for inspiration? If you go out to eat, just be curious and pick the restaurant you always wanted to try, yet ending up at the same place you always went. This doesn’t only increase your daily diversity, but also the one across days, which is especially important: Imagine you create a super diverse menu and then eat it day after day after day… Sounds boring, right? Your gut will share this opinion! My extra tip: Choose restaurants that offer a buffet every now and then. This is specifically handy around lunchtime because you don’t have to wait for your food. Again, take a bit of everything, but be careful not to overload your plate. This gives you the chance to try out what you like when you taste a novel cuisine. And imagine the looks you get when you say “Hey, I’m doing this for my microbiome!”

Join a food cooperative
You know that homemade cooking is great. You are in charge of what goes into the pan, you control the ingredients’ quality. But, of course, it requires planning, shopping, cooking – not to forget cleaning the kitchen. An easy step towards a diverse, regular cooking habit is joining a cooperative or booking home delivery from organic farms nearby. You get a box full of seasonal, fresh, local fruit and veg delivered to your door weekly. If you know where it comes from, you might be more reluctant to throw it out, hence you might actually cook it and eat it! The surprising variety of what a season has to offer will boost your cooking creativity and enhance your nutritional diversity even further.

Some might object now and remark that when they look at the back of their ready-to-eat supermarket meals, is states that there are so many ingredients in one package, that there is no need to enhance nutritional diversity even more. Sure, there is a point there! But keep in mind that these foods are massively processed, thus having lost many of the original ingredients’ benefits like vitamins, etc. Also, if you look closely, you might detect declarations you don’t even know what they mean! Those different additives, like E-numbers, are mostly artificially produced, and there is long-term research missing what they actually do to our bodies – especially in interaction with all the other additives found in processed food. Don’t get me wrong – every now and then I also grab a bag of ready-to-eat food from the counter.
But what I personally do is to subtract the artificial ingredients from my daily diversity calculation (and now you also know that I like math).

Distribute your homemade meals across different days
This is the same approach as eating a set menu. Imagine you make yourself a nice pasta dish for the evening, and prepare a mixed salad for lunch the next day. How about splitting both in half? That way you expand your food across days, yet adding more daily eatables at the same time. Your microbiome will like the variety that goes along with this. Plus, you don’t have to buy canteen food the next day and might save some money – money that could be spent at the fancy restaurant we talked about earlier on!

And yes, distributing food across days also applies to cake and desserts. If you baked a cake (consider adding lots of fruit), have one piece now and one tomorrow! And remember to send your mum a picture of your delicious achievements, she will love it!

Experiment with seasonings
If you go through the seasonings in your kitchen cupboard, you will notice that some seasonings provide a literal boost for your nutritional diversity. I just found a curry powder with 13 ingredients! Of course, if you start and mix different seasonings, a few compounds will be redundant. But when you cook – or simply heat up a bought dish – add that little extra. That way, you can even reduce the amount of salt without giving up on flavour. The world health organization recommends 5 grams of salt per day (2). Simply use high-quality seasoning and herb mixtures instead, maybe add a drop of fine oil for flavour, and let it surprise you!

Try smoothies and soups
For a quick energy boost in the morning, I recommend a smoothie. What I love about smoothies? You can virtually throw everything in there, and by adding just a few ingredients for flavour (like oranges) and texture (like bananas) you can create a tasty and always different vitamin shot. Again, remember seasoning like curcuma or cinnamon to increase variety and diversity. For later meals, there are great recipes for soups – even some that don’t require cooking! If you blend your soup, you can easily ‘hide’ some leftovers in there, or some bits of a vegetable you don’t really like.

Share your meals
This is my favourite tip. Have you noticed that also during lunch with colleagues, the grass is always greener on the other side? In our lab, we have switched to a food sharing concept where everybody can take a bit of everyone’s meal. In some cultures, like Corea, it is common to place all the food one orders in the middle of the table. They know that sharing is caring – especially caring about one’s microbiome diversity!

And last, not least: Avoid antibiotics!
Of course, there are some illnesses where antibiotics are essential. But did you know that animals are fed large amounts of antibiotics, and that we consume them, too, when we indulge into our chicken breast or piece of veal? These antibiotics not only kill unwanted microbes, they also heavily disrupt the ecology of our microbiome (3). So in order to keep your gut happy and to get the most out of your nutritional diversity experiment, think twice before you buy or order conventionally produced meat. Consider organic meat or vegetarian alternatives – hence adding even more possibilities for a diverse menu.

(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577372/
(2) http://www.who.int/news-room/fact-sheets/detail/healthy-diet
(3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4831151/

Want to learn more? Visit http://www.bbc.co.uk/guides/zpf27hv#z8qrg82 for a little quiz and some more information and https://experiencelife.com/article/your-microbiome-the-ecosystem-inside/ to find out more about your microbiome.

 

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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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Tips Against Overeating

Have you ever noticed that the type of food you eat can affect how you feel afterwards? Some food might make you wish to rest and relax, some food might give you the little extra energy you just needed. Evidence is accumulating that also in the long run, diet may play a pivotal role for your mental health. For example, it might have an effect on impulsive and compulsive behaviour [1].
But it’s not only the diet that affects our body, mind and brain – it’s also the amount of what we eat. Research shows that people don’t necessarily know what a suitable amount of food might be. Sure you can imagine that this can easily lead to obesity – which in turn can impair our general health.

A meta-analysis (that is, a study that investigates an effect among many independent studies that have been conducted so far) from 2018 came to the conclusion that serving size and the size of the tableware has an effect on the amount we eat: When offered larger-sized portions, packages or tableware, participants ate or drank more than when offered smaller-sized versions [2].

British nutritional scientists now developed a guideline for the British Nutrition Foundation (BNF) to help people estimate the suitable serving size. For example, they recommend that when having a pasta dish, you should take as much pasta for one person as fits into both of your hands (before cooking). A portion of fish or meat should be about half the size of your hand. However, this does not mean that when you eat more than one portion, you are an overeater.

According to their tipsheets, which can be found here,
https://www.nutrition.org.uk/healthyliving/find-your-balance/portionwise.html
one should compose his or her daily menu based on a mixture of different portions. For example, 3-4 portions of starchy carbohydrates (such as the above-mentioned pasta) are recommended daily. Their guidelines, however, offer a few handy (literally!) advises to help you get a sense of how much food you should consume, thus preventing you from overeating. With a few simple tips kept in mind, you can do some good for your physical and mental health, daily.

REFERENCES
[1] Sarris J, Logan AC, Akbaraly TN, Amminger GP, Balanzá-Martínez V, Freeman MP, et al. Nutritional medicine as mainstream in psychiatry. Lancet Psychiatry. 2015; 2(3):271-4.
View here:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/fulltext

[2] Hollands GJ, Shemilt I, Marteau TM, Jebb SA, Lewis HB, Wei Y, Higgins JPT,
Ogilvie D. Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco. Cochrane Database of Systematic
Reviews 2015, Issue 9. Art. No.: CD011045. DOI: 10.1002/14651858.CD011045.pub2
View here:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011045.pub2/full

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