From The December 1998 Issue of Nutrition Science News
by Marcia Zimmerman, C.N.
The right diet and supplements can make drugs unnecessary for kids with ADD and ADHD
Food, while nourishing, can also energize or subdue, comfort or agitate. A growing body of evidence implicates diet in the commonly diagnosed attention deficit disorder (ADD). Simple meal modification may eliminate the need for the frightening array of drugs being prescribed to control children. Diet can mean the difference between a normal childhood and years of difficult behavior or behavior-modifying drugs.
Attention deficit disorder is the fastest-growing childhood disorder in the United States.  A corresponding condition is called attention deficit hyperactivity disorder (ADHD), or ADD with hyperactivity. The American Psychiatric Association has published criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)  to distinguish between two categories of ADHD (the term ADD is outdated but still popular): ADHD inattentive and ADHD hyperactive-impulsive. A third category is a combination of these two. For purposes of clarity in this article, I will use ADD to designate the inattentive type and ADHD for the hyperactive-impulsive and combined types.
By January 1998, about 4 million children--an astounding 10 percent of the entire school-age population--were diagnosed with either ADD or ADHD.  In some areas of the country, about half the children in schools are labeled "victims" of these mysterious, mentally disabling disorders du jour. More alarming, 13 million adults suffer from ADD or ADHD, bringing the total to 17 million Americans struggling with these conditions. These burgeoning numbers worry some government experts, including those at both the National Institute of Mental Health (NIMH) and the Drug Enforcement Agency (DEA) in Washington, D.C., who wonder if ADD and ADHD are being overdiagnosed and patients overmedicated.
Gene Haislip, a former deputy assistant administrator at DEA, is concerned about the proliferation of attention deficit diagnoses. "With the exception of AIDS, there are few examples of such a rapid spread of a serious condition in recent years," he says. And Haislip wonders, "Why are we rushing to feed stimulants [such as methylphenidate in the form of Ritalin [TM]] to children?" 
There are people who carelessly apply the labels ADD and ADHD to a variety of behaviors as if they were designer disabilities, but both are valid psychiatric disorders with serious consequences, most notably the use of powerful drugs to control symptoms.
The inattentive ADD child is often more difficult to diagnose because inattentive behavior is not as obvious as hyperactivity. Nevertheless, the inability to get started or finish tasks jeopardizes the child's functioning both at home and at school. The inattentive ADD individual procrastinates and rarely completes anything. This kind of ADD is the most likely to persist into adulthood, affecting a person's ability to succeed in a career or relationships.
The hyperactive or impulsive youngster attracts attention by constantly disturbing others. Children with this kind of ADHD can pay attention. In fact, they engage themselves for hours in tasks that interest them. Adults with hyperactive or impulsive behaviors are always on the go and constantly in motion, but they get things done. However, they tend to be impatient and quick to fly off the handle.
Some children have a combination of ADD (inattentive) and ADHD (hyperactive-impulsive). These children have the most difficulty succeeding, and their self-esteem takes a constant beating. Children and adolescents with combined ADHD are often unpopular because they don't wait their turn and frequently interrupt conversations. They lack responsibility, do not follow instructions, are often clumsy and awkward, and are likely to have learning disabilities. These individuals do not readily accept change and can become agitated when their schedule is upset, because they do not adapt well.
To qualify as any type of ADHD, the behavior must have occurred before the age of 7 and in a persistent and disabling pattern for at least six months. In other words, the child must have great difficulty functioning in school and/or at home. According to John Ratey, M.D., a Boston psychiatrist specializing in ADHD, "The behavior must be serious enough to be disabling."  The DSM-IV criteria seem clear, and the conditions qualifying as ADHD behaviors are specific, yet many individuals are prescribed medication without being properly evaluated  --leading many people to question what constitutes an accurate ADHD diagnosis.
A diagnosis should be accepted only after a thorough evaluation by a team of professionals who specialize in the disorder. Psychologists, psychiatrists and social workers with special training are qualified. Neurologists, pediatricians and general practitioners usually are not qualified, even legally, to independently diagnose the condition. Pediatricians, internists and general practitioners should, however, rule out medical conditions that may account for the symptoms.
Because there are no laboratory tests to identify the disorder, ADHD must be diagnosed from medical history in addition to parent, teacher and psychiatric observations. There are tests to measure ADHD behavior, including the ability of the patient to concentrate and process information. Not surprisingly, ADHD children often have trouble with abstraction. Many think in complete pictures rather than being able to isolate pieces of information and reorganize them into complete ideas.
In the 1990s, however, brain imaging techniques such as positron-emission tomography (PET) have provided clues to the causes of ADHD. PET scans have been used to characterize abnormalities, such as impaired glucose metabolism, seen in ADHD patients. Since a child's brain uses up to half of his or her daily caloric intake for energy needs, reduced glucose availability limits brain function dramatically. Scientists at NIMH, for example, have provided vital information on glucose processing in the ADHD brain, so appropriate nutritional programs can be designed to alleviate ADHD symptoms throughout life. [6-8] ADHD has several causes, including nutrition and food sensitivities, genetic predisposition, neurotransmitter imbalances and environmental factors, but the emphasis of this article is nutritional influences.
Diet's Far-Reaching Effects
Studies are racking up evidence linking diet to both health and behavior--including ADD and ADHD. In addition, several studies show that American children and adolescents aren't eating balanced, high-quality diets.
Startling evidence of the prevalence of poor-quality diets was revealed in the U.S. Department of Agriculture (USDA) dietary survey of 3,300 U.S. children and adolescents. The survey showed that less than 1 percent meet the recommended daily requirements for the five food groups. A whopping 16 percent do not meet any of the requirements. [9 ]
In 1994, Australian researchers Katherine Rowe, M.D., and Kenneth Rowe, Ph.D., found that 55 percent of the children who responded favorably to elimination of all food dyes and additives subsequently reacted when fed a single dye such as tartrazine or yellow dye No. 5 at various dose levels. The behavioral changes noted were irritability, restlessness and sleep disturbances.  A year later, Marvin Boris, M.D., and Francine Mandel, Ph.D., from North Shore Hospital, Cornell Medical Center, in Manhasset, N.Y., evaluated 26 ADHD children and found that 73 percent (19) responded favorably to a multiple-item elimination diet. If a child reacted to an item, it was withdrawn and subsequently challenged to confirm the reaction. All 19 children reacted to many foods, dyes and preservatives. [11 ]
N.L. Girardi, M.D., and colleagues at Yale University School of Medicine in New Haven, Conn., studied differences in the response to sugar in 17 ADHD and 11 normal children.  After an all-night fast, the children drank a glucose beverage containing eight times the sugar the brain uses in one hour.
response to a sugar onslaught is an outpouring of insulin, which quickly reins in rising blood sugar levels. The adrenal glands release norepinephrine and epinephrine--catecholamine hormones--to counterbalance a rapid drop in glucose caused by high insulin levels.
Both groups of children were given a battery of tests three hours after their sugary meal to measure cognitive performance. Results showed ADHD children had released only half the amount of catecholamines as the normal children. ADHD children's PET scans showed markedly reduced brain activity caused by insufficient glucose for processing information. Not surprisingly, their test scores were much worse than those of the children who did not have ADHD.
Sugar did not affect the ADHD children uniformly, however. Many became increasingly hyperactive during the three- to five-hour period following the glucose breakfast. The research teams concluded that the children were jumping around in an unconscious biochemical attempt to get their adrenal glands to pump more epinephrine and norepinephrine into their brains. There still exists considerable controversy regarding sugar's effect on hyperactive behavior, largely because testing protocols are not standardized. Therefore, children tested under different conditions do not respond the same. For example, the response to sugar is greatest when it is given first thing in the morning on an empty stomach. The effects are dampened when it is eaten later in the day or after a meal containing protein.
Other ADHD children in the Girardi study became calm after the sugar surge; their bodies locked onto another of sugar's effects--carbohydrates, especially sugar, raise serotonin levels in the brain, which causes drowsiness.  Protein, on the other hand, raises catecholamine levels and is arousing. Parents can test their child's reaction to sugary foods first thing in the morning and after a protein-containing meal to determine the child's response. In most cases, it is best to feed the child complex carbohydrates and eliminate simple sugars. Emphasis should also be placed on protein foods for breakfast and lunch and complex carbohydrates for dinner. Adjust snacks based on when they are to be eaten.
By customizing the diet and supplementing with missing nutrients, the faulty communication in a child's or an adult's brain can be repaired and behavior modified. This process begins with understanding how the body uses food and what effects protein, carbohydrates and fats have on the brain and behavior.
Protein foods are often poorly digested by ADD and ADHD children, especially if they are food-sensitive. Some psychiatrists report lessened hyperactive behavior in their patients after adding a digestive enzyme to each meal. The child must digest proteins to have a sufficient supply of the amino acid precursors needed by brain neurotransmitters. I prefer to use the diet to supply a spectrum of amino acids from protein rather than supplementing with individual amino acids like L-tyrosine and L-phenylalanine, or the metabolites melatonin and 5-HTP. Brain chemistry in ADHD patients is already unbalanced, and the wrong amino acids or metabolites can worsen the condition. A physician can have lab tests run to determine which neurotransmitters are in short supply and subsequently prescribe an appropriate amino acid regime.
Dietary carbohydrates must be from complex, whole-grain sources, and they should be wheat- and corn-free because these frequently cause reactions in ADHD children. Complex carbohydrates such as legumes and vegetables supply the glucose necessary for brain function without the rapid insulin response that upsets glucose metabolism.
As is well-known by now, processed and fried foods usually contain saturated, hydrogenated and trans fats--the wrong kinds of fats. These fats wreak havoc with the fatty acids needed for the brain's neuron activity. In addition, ADHD children typically have low docosahexanoic acid (DHA) levels. DHA is the primary fatty acid in brain, nerve, eye and heart tissues, where it functions within cellular membranes to secure the signaling devices for communication between cells.  Typical dietary sources of DHA are oils from deep-sea cold-water fish, green seafoods, and animal products. Flaxseed oil is a precursor of DHA, but many factors including the wrong dietary fats, namely saturated and trans fats, can interfere with its conversion to DHA.
Children need the right kind of fats for their rapidly developing brains and nerves and should be fed smart-fat rather than low-fat diets. The brain is 60 percent fat, most of which is DHA. Arachidonic acid (AA), an omega-6 fatty acid, is also in plentiful supply in brain membranes. Both DHA and AA are attached to phosphatides in neuronal membranes, forming a network that holds the neuronal receptors and channels in place.  These channels are the communication devices of neurons.
Too much of the wrong fats leaves the brain starved for DHA and AA. The brain will grudgingly substitute the wrong fats into neuronal membranes, but the membrane architecture is then changed, and the receptors no longer align properly, which results in garbled and unclear messages. The ADD or ADHD individual describes the result as similar to having the television tuned into all channels simultaneously with the volume on high.
The strategy for fats is to eliminate the bad ones and supply enough essential fatty acids, particularly DHA, to reconfigure neuronal membranes. The body is better able to satisfy AA needs, and DHA helps keep the body in balance. Currently, two ADHD studies are under way, supplementing 300-400 mg DHA per day.
Nutrition: The Best Medicine
A complete program for a person with ADD includes supplements in addition to careful meal planning. Noticeable improvement in behavior is often seen with the following supplements:
B-complex supplements are required to assist the brain enzymes that process carbohydrates for energy and to regulate neurotransmitters.
DHA is often present at lower levels in ADHD children than in normal children, as mentioned previously. Optimizing levels of this fatty acid has been clinically shown to improve behavior in ADHD children. Several companies supply DHA supplements made from microalgae, and one supplies a combination of DHA, AA and gamma-linolenic acid. I do not recommend supplementing with the fatty acid precursors linoleic and linolenic acid because neither children nor adults can convert them in sufficient quantities to meet the body's need for DHA and AA. It's a good idea to increase consumption of fatty cold-water fish such as salmon, herring and tuna, all rich sources of DHA.
Vitamin C and proanthocyanidins (found in grape seed extract) are essential for several brain functions. Vitamin C is needed to manufacture neurotransmitters, and the proanthocyanidins modify enzymatic activities including catecholamine transfer enzyme.  Proanthocyanidins also prevent vitamin C from being oxidized or interacting with copper and iron to produce free radicals. Choosing the correct proanthocyanidin can be tricky because there are so many generic grape seed extracts. Check with your retailer to ascertain the quality.
Zinc and magnesium supplementation in addition to a multimineral is a good idea because deficiencies in both zinc and magnesium have been associated with ADHD. Magnesium levels appear to be low in patients with ADHD, and supplementation has reduced hyperactivity.  Zinc deficiency in ADHD children was associated with low fatty acid levels, and the relationship between the two was studied by a Polish team. Of 48 ADHD and 45 normal children, the ADHD group had significantly lower zinc and fatty acid blood levels. [18 ]
Nutrition offers parents what they really want -- a way to beat ADD and ADHD. Sometimes medication provides a quick solution by masking the symptoms, but it doesn't really offer long-term hope. Only nutrition combined with behavioral therapy can do that.
Methylphenidate (Ritalin) Facts
ADD Or ADHD? Narrowing the Diagnosis
1. The Merrow Report. Attention deficit disorder: a dubious diagnosis? 1995 Oct 20.
2. American Psychiatric Association Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.; 1994.
3. Haislip G. (former deputy assistant administrator, Office of Diversion Control, U.S. Drug Enforcement Agency), in a DEA address. Washington, D.C., 1996 Dec.
4. Ratey J. Fourth Annual Mind/Body Conference--Driven to Distraction; 1998 Jun 11, Santa Maria el Mirador.
5. Jureidini J. Some reasons for concern about attention deficit hyperactivity disorder. J Paediatr Child Health 1996;32:201-3.
6. Ernst M, Zametkin A. Psychopharmacology: the fourth generation of progress. New York: Raven Press Ltd; 1995. The interface of genetics, neuroimaging and neurochemistry in ADHD; p 1643-51.
7. Ernst M, et al. Reduced brain metabolism in hyperactive girls. J Am Acad Child Adolesc Psychiatry 1994 Jul-Aug;33(6):858-68.
8. Zametkin A, et al. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. NEJM 1990 Nov;323(20):1361-6.
9. Mu-oz KA, et al. Food intakes of U.S. children and adolescents compared with recommendations. Pediatrics 1997 Sep;100(3):323-9.
10. Rowe Katherine, Rowe Kenneth. Synthetic food coloring and behavior, a dose response effect in a double-blind, placebo-
controlled, repeated-measures study. J Pediatr 1994;125:691-8.
11. Boris M, Mandel F. Foods and additives are common causes of the attention deficit hyperactive disorder in children. Ann Allergy 1993;72(5):462-7.
12. Girardi NL, et al. Blunted catecholamine responses after glucose ingestion in children with attention deficit disorder. Pediatr Res 1995 Oct;38(4):539-42.
13. Spring B, Wurtman RJ. Effects of foods and nutrients on the behavior of normal individuals. In: Wurtman JJ, editor. Nutrition and the brain. Volume 7. New York: Raven Press; 1985. p 1-47.
14. Stevens L, et al. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. Am J Clin Nutr 1995;62:761-8.
15. Crawford MJ. The role of essential fatty acids in neural development: implications for perinatal nutrition. Am J Clin Nutr 1993;57(Suppl):703S-10S.
16. Roger CR. The nutritional incidence of flavonoids: some physiological and metabolic considerations. Experientia 1988 Sep 15;44(9):724-804.
17. Starobrat-Hermelin B, Kozielec T. The effects of magnesium physiological supplementation on hyperactivity in children with attention deficit hyperactivity disorder (ADHD). Positive response to magnesium oral loading test. Magnesium Res 1997;10(2):149-56.
18. Bekarolu M, et al. Relationships between serum-free fatty acids and zinc, and attention deficit hyperactivity disorder: a research note. J Child Psychol Psychiatry 1996;37(2):225-7.
Marcia Zimmerman, C.N., is founder and CEO of The Zimmerman Group Inc., Alameda, Calif. She is a former researcher at Stanford University School of Medicine, and author of The ADD Nutrition Solution: A Drug-Free 30-Day Plan (Henry Holt/Owl Books, 1999).