Dietary Interventions
for AttentionDeficit/Hyperactivity
Disorder
Ashley Walther
DSM-V Definition of ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or
development:
Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults;
symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus,
side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or
homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile
telephones).
Is often easily distracted
Is often forgetful in daily activities.
Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for
adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that
is disruptive and inappropriate for the person’s developmental level:
Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often "on the go" acting as if "driven by a motor".
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting his/her turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games)
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Prevalence:
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Causes:
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Children: 4-5%
Adults: 4.7% worldwide
Genetic
Environmental
Psychosocial
Treatment:
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Typically multifaceted
Stimulant medications
 Behavior modification/psychotherapy
 Unconventional approaches
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Nutritional interventions
Dietary Approaches
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A subset of individuals display hypersensitivity
to various food components
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Overall healthy diet
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Essential fatty acids
Specific micronutrients
Avoid processed foods/sodium/saturated
fat/refined sugars
Hypersensitivity
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Allergic
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Triggered by immune response
Dopamine transporters causally linked to ADHD
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Children with ADHD have a higher rate of allergic disease
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Found in abundance on human T-cells
Trigger secretion of immune regulatory cytokines
67.5% of children with ADHD test positive for allergies, vs. 45% of controls
Non-allergic
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May occur via immunoglobulin-independent histamine release from mast cells
and basophilic granulocytes
History of Research
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1973: Dr. Benjamin Feingold developed
Kaiser-Permanente (K-P) Diet
Free of all foods containing natural
salicylates as well as all artificial colors
and flavors
Reported that 60-70% of his patients
improved on this diet
Problems:
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No structured diagnosis, control groups or
double blind conditions
Based on subjective data
no statistical
analysis possible
Meta-analyses of studies indicate that only
11-33% of children respond to diet
Diet is difficult to follow, many kids dislike it,
and diet provides less calcium, riboflavin
and vitamin C than baseline diets
Artificial Food Colors
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Small amounts of artificial
food colors can cause
irritability, restlessness, sleep
disturbances and
impulsivity in children who
are sensitive to them
In non-hyperactive
samples, there is a smaller
but still significant
relationship between
artificial food colors and
hyperactivity
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Food manufacturers in the
United Kingdom have
been forced to eliminate
several artificial food dyes
from their products
Elimination Diet Studies
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Phase 1: only a few hypoallergenic foods are consumed for 25 weeks
Chocolate
Grains
Avoid
All artificial colors, flavors
and preservatives
Dairy (cow’s milk,
cheese, yogurt, ice
cream)
Chocolate
Wheat, rye, barley
Meats/Poultry/Fish/Eggs
Eggs, processed meats
Fruits
Vegetables
Citrus
Legumes (peanuts,
beans, peas, etc.), soy,
corn, corn oil, corn syrup
Peanuts, peanut oil
Additives
Milk
Nuts
Consume
Rice milk
Oats, rice, rice
cakes/crackers, rice
noodles
Unprocessed meats,
poultry, fish
All other fruit
All other vegetables
Walnuts, pecans,
almonds, etc. (not
processed with
peanut/soy oil)
 Phase
2: if child responds to diet, gradually
reintroduce foods suspected of producing
behavioral response one at a time
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Approximately 70% of children have been shown to
respond to elimination diets
“Western” Diet and ADHD
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“Western” diet: high in saturated/total fat, sodium and
refined sugars, low in omega-3 fatty acids, folate and fiber
“Healthy” diet: low in saturated fat, sodium and refined
sugars, high in omega-3 fatty acids, folate and fiber
Consumption of western style diet and processed foods
associated with:
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Higher rates of ADHD diagnosis
Impairment of memory/working memory, attention, inhibitory
control and reward processes
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possibly a result of long-term changes to neuron function
Hypothesized that high consumption of food additives in
processed foods may interact with inadequate
micronutrient intake to produce ADHD symptoms
Specific Nutrients
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Iron
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84% of children with ADHD had serum ferritin levels >30
ng/mL vs. 18% of control group
Supplementation of 80 mg/day for 12 weeks associated
with a significant reduction in ADHD symptoms
Zinc
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cofactor for dopamine metabolism
Low zinc levels have been correlated with inattention
based on parent and teacher ratings
Low levels of zinc in serum, hair, urine and nails of
children with ADHD
Zinc supplements of 30mg/day for 8 weeks enhance the
effects of stimulant medication
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Lowered required dose by 37%
Polyunsaturated Fatty Acids
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Children received supplements for 12 weeks
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400mg EPA
40mg DHA
60mg gamma-linolenic acid
80mg magnesium (2% RDA)
5mg zinc (50% RDA)
Results indicated significant improvements in
attention, hyperactivity, impulsivity and emotional
and behavioral problems
Supervising physicians recommended that 61% of
participants continue taking the supplement
Special Considerations
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Because ADHD is a psychiatric disorder, treatment
will also involve physician/mental health provider
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May be necessary to work with prescribing physician,
particularly if recommending a restricted elimination
diet
Those with food sensitivities will need individualized
diets to omit the offending food(s)
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Many take stimulant medications to manage symptoms
Depending on the food omitted, supplements may be
necessary to prevent deficiency
Checking serum ferritin and zinc levels may be
recommended, and supplements for these and
essential fatty acids may be warranted
Potential Difficulties
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Restricted elimination
diets are time consuming,
difficult and are often not
well tolerated by children
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Foods that produce
behavioral effects are
typically frequently
consumed and enjoyed
Avoiding artificial food
additives can be difficult
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Necessary to educate
clients in reading
ingredients
Provide lists of additives
and “safe” foods
FD & C
Number
Blue #1
Common
Name
Brilliant Blue
Type of
Chemical
Triphenylmet
hane
Shade
Blue #2
Indigotine
Dark Blue
Green #3
Fast Green
Sulfonated
Indigo
Triphenylmet
hane
Yellow #5
Tartrazine
Azo Dye
Yellow
Yellow #6
Sunset Yellow
Azo
Orange
Citrus Red #2
Citrus Red
Azo
Orange
Red #3
Erythrosine
Xanthene
Dye
Pink
Red #40
Allura Red
Azo
Red
Orange B
Azo
Blue
BlueGreen
Foods
Containing Color
Beverages,
candy, baked
goods,
ice cream,
cereals
Beverages,
Candy
Beverages,
candy, gelatin,
jellies
Gelatin, candy,
chips, ice
cream,
cereals, baked
goods, pickles
Beverages, jam,
sausages, baked
goods, candy,
gelatin
May only be
used on skins of
some Florida
oranges
Candy, baked
goods,
popsicles,
cereals
Candy,
beverages,
gelatin,
pastries,
sausages,
cereals
Hot dog and
sausage casings
only
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Impulsivity can make following a prescribed diet difficult
Children may experience difficulty in school and adults may
have a long history of academic, occupational or
interpersonal problems
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Find a balance between empathy and challenging inconsistent behaviors
Substance Abuse and ADHD
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Rates of ADHD among active substance abusers
range from 14-33%
Substance abuse can increase risk of nutrient
deficiencies
May worsen symptoms or lead to noncompliance
Obesity and ADHD
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Obesity:
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With ADHD: 29.4%
Control: 21.6%
Overweight:
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With ADHD: 31.9%
Control: 28.8%
• Estimated that
21-61% of
patients seeking
weight loss
treatment meet
the criteria for
ADHD
 After
participating in a 16-week behavioral weight
loss program, participants with ADHD:
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Lost significantly less weight
Were less likely to lose more than 5% of body weight
Consumed fast food more frequently
Were more likely to eat in response to negative moods
Reported more frequent weight loss attempts and
greater difficulty with weight loss skills like tracking
calories, keeping food records and meal planning
 May
be necessary to give extra instruction and support
with these skills
Counseling Techniques
 Techniques
associated with cognitive
behavioral therapy may be useful
regardless of whether weight loss is a goal
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Role playing and modeling
 May
help a child or adult with ADHD practice
more acceptable behaviors involving food
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Meal planning, shopping and organization
Delay and distraction
 May
help in learning to manage impulsivity
Sample Menu
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Breakfast
 1 cup sliced strawberries
 ½ cup skim milk
 1 cup multigrain Cheerios
Morning Snack
 ¾ cup sliced carrots
 3 tablespoons hummus
Lunch
 3 ½ oz. hamburger patty (95% lean) with 1 oz. cheddar cheese, 1 thick slice of tomato and 1 whole
wheat hamburger bun
 1 ½ cups mixed greens with ½ cup sliced cucumber, 1 ½ tablespoons flaxseed oil and 1 tablespoon
red wine vinegar
Afternoon snack
 1 medium apple
 1 fat free string cheese
Dinner
 4 oz. skinless salmon (broiled) with 2 tablespoons hollandaise sauce
 1 cup brown rice
 1 cup broccoli with cheese sauce
 1 whole wheat dinner roll
Evening snack
 1 fat free Greek yogurt
 1 graham cracker (2 squares)
*Choose brands free of artificial colors/flavors/preservatives
 Total
calories: 1,980
 Linoleic Acid: 10 g
 EPA: 595mg
 DHA: 843mg
 Iron: 30mg
 Zinc: 30mg
 Sodium: 2433mg
 Saturated fat: 24g