A nutritional approach to the management of ADHD

by Dr. Joseph Debé

If the only tool you have is a hammer, everything looks like a nail. Attention Deficit/Hyperactivity Disorder (ADHD) is yet another nail that conventional medicine and the pharmaceutical industry are pounding with their hammer – patentable, lucrative, synthetic chemicals. However, ADHD is no more the result of a Ritalin deficiency than headaches are a Tylenol deficiency. What is needed is a bigger tool kit, one with safer and more versatile tools.

ADHD is the name given to a collection of symptoms that includes short attention span, distractibility, impulsivity, hyperactivity, and emotional lability of a degree that results in impairment of social, academic or occupational functioning. Learning disabilities, anxiety, depression, and anger control problems are commonly associated with ADHD as well. ADHD begins in childhood and often continues into adulthood. 

Conventional medicine typically treats ADHD solely with administration of central nervous system stimulants. Ritalin is the most commonly prescribed of these. Ritalin's biochemical action is very similar to that of cocaine and amphetamines and it does carry the potential for abuse. It is somewhat beneficial in about 70% of cases. However, it can produce undesirable side effects, including loss of appetite, abdominal pain, weight loss, rapid heartbeat, nervousness, insomnia, dizziness, headache, drowsiness, and psychosis and more. The Physicians' Desk Reference contains the following information regarding Ritalin: "Sufficient data on safety and efficacy of long-term use of Ritalin in children are not yet available. Although a causal relationship has not been established, suppression of growth (i.e., weight gain, and/or height) has been reported with the long–term use of stimulants in children. Therefore, patients requiring long-term therapy should be carefully monitored…Ritalin should be periodically discontinued to assess the child's condition. Improvement may be sustained when the drug is either temporarily or permanently discontinued. Drug treatment should not and need not be indefinite and usually may be discontinued after puberty." A mouse study found Ritalin to cause liver cancer at a dosage equivalent to just 2.5 times the maximum-prescribed human dose. Although the relevance of this study to humans is questionable, it should be noted that the U.S. Toxicology program considers Ritalin a "possible human carcinogen".

Another problem with Ritalin and the other medications used to treat ADHD is that they do not address underlying causes. So what? Suppressing symptoms of ADHD without removing underlying causes allows damage to continue in the body. This will become clearer shortly and is a concept that applies to all multifactorial conditions that are "treated" with symptom–suppressing medication. It is my belief that the underlying causes of ADHD include genetic predisposition, nutrient insufficiencies, dietary imbalances, food and chemical sensitivities, toxicity, abnormal stress response, and low thyroid function. 

All structure and function in the body is dependent upon the foods we eat. The brain is no exception. Dopamine, the neurotransmitter (brain messaging chemical) that appears to be the target of Ritalin's action, requires adequate levels of iron, copper and vitamin B6 for its production in nerve cells. Iron deficiency symptoms include shorter attention span, decreased persistence and reduced activity levels. Iron supplementation produced a 30% improvement in a study of boys with ADHD. 

A study of six children, ages 8 to 13, compared the effects of vitamin B6 to Ritalin and to placebo in a 21–week double–blind crossover trial. This means each child was given each of the three treatments at different times and neither the subjects nor the investigators knew which treatment was being given until the study was complete. Based on teachers' ratings, vitamin B6 was found to be slightly more effective than Ritalin.

Zinc, a mineral I find many people lacking, regulates the release of neurotransmitters. Some of the symptoms resulting from zinc insufficiency include altered regulation of emotions and deficits in learning and attention. Several studies have found ADHD patients to be lacking in zinc. 

Magnesium deficiency is associated with ADHD. A study of 75 children with ADHD and magnesium deficiency found magnesium supplementation improved all measures of hyperactivity. Another study found 95% of 116 ADHD children to be lacking in magnesium. When supplemented with magnesium, hyperactivity improved significantly. 

Vitamin B6, zinc and magnesium share a biochemical function that relates to ADHD. All three are required for the synthesis of long–chain fatty acids in the body. Children with ADHD have been found in several studies to have lower levels of these long–chain fatty acids, including docosahexaenoic acid (DHA), arachidonic acid (AA), eicosapentaenoic acid (EPA), and dihomo-gamma linolenic acid (DGLA). DHA and AA are normally the most abundant fatty acids contained in the brain's cell membranes and influence the function of the membrane and how messaging compounds bind to the cell. DHA deficiency decreases dopamine levels and the number of dopamine receptors.

Vitamin B1, deanol, and phosphatidylserine (PS) are additional supplements found to benefit ADHD subjects. PS, a normal component of cell membranes, plays a role in dopamine synthesis, release and activity. PS appears to improve attention and learning more than behavior. I have some concern over the use of PS, as I have seen it result in abnormally low cortisol levels. I recommend for ADHD patients to have their nutritional programs closely monitored by a qualified health care professional.

Aside from poor diet, there are other causes of nutrient insufficiencies. For example, high levels of the stress hormones epinephrine (adrenaline) and cortisol can cause excess magnesium excretion in the urine. Chronic stress and high sugar intake both raise epinephrine, which over the long–term lowers dopamine levels. A study of 261 hyperactive children found abnormal glucose tolerance in response to a sugar feeding in 74%. A study of ADHD children found abnormal cortisol levels in over half the subjects. Cortisol, as opposed to epinephrine, is a long–acting stress hormone. Cortisol levels increase in response to any mental–emotional, physical, or metabolic stressor. Mental–emotional stress, swings in blood sugar, inflammation, and toxicity are some of the more common factors.

A source of toxicity I feel plays a role in many cases of ADHD is intestinal dysbiosis, or imbalanced intestinal flora. Each of us normally has about 100 trillion bacteria (comprised of 400 different species) residing in our intestinal tracts. Some species are beneficial, some not so beneficial to our health. Then there is also a number of yeast normally inhabiting our digestive tracts. They tend to over proliferate, however, in response to a high sugar diet and use of antibiotics. Certain intestinal organisms produce metabolic byproducts that are poisonous to our brains. When there is an overgrowth of certain species of bacteria or yeast, a wide variety of mental-emotional symptoms can result. One study found a third of ADHD subjects to have yeast overgrowth, 65% had parasites, and 75% had "Leaky Gut Syndrome". "Leaky Gut Syndrome" is a condition involving breakdown of the intestinal lining, which normally performs two very important functions: nutrient absorption and toxin exclusion. A weakened or leaky gut allows increased systemic access to intestinal toxins while nutrients are less well absorbed. Another study found ADHD symptoms improved when subjects were supplemented with oligosaccharides, a fiber that feeds "friendly" intestinal bacteria.

Food is not only important in ADHD because of nutrient content and impact on intestinal flora but because of the potential for food sensitivity reactions. Mental–emotional changes are among the myriad symptoms that can result from food sensitivities. Two published double–blind, placebo–controlled studies found about 75% of ADHD children improved when certain foods were removed from their diet. Although a given individual can react to any food, the most common culprits are dairy products, wheat, corn, yeast, soy, citrus, egg, chocolate, and peanuts.

Synthetic chemicals added to foods can also contribute to ADHD. A medical doctor by the name of Feingold found that about half of his hyperactive pediatric patients were sensitive to food additives (dyes, flavorings, preservatives) or to salicylates, compounds naturally occurring in some foods. It is interesting that Ritalin, like many medications, contains artificial colors. A recent review examined the results of nine double–blind studies on the effects of food additives on ADHD children. In eight of these studies some children had a worsening of ADHD symptoms upon exposure to food additives. 

Environmental toxins also appear to play a role in ADHD. Heavy metals, molds, dusts, pesticides, and many others have been found to produce cognitive/behavioral symptoms. Two studies on lead body–burden found a significant impact on ADHD–type symptoms. One study of 277 first–grade children found 13.5% of those with hair lead levels below 1 part per million (ppm) were rated by teachers and doctors as having ADHD. For the children with lead levels of 6 or more ppm the incidence of ADHD soared to 62.5%. The other study, published in the New England Journal of Medicine in 1979, examined 2146 first and second-graders from an upper–middle class Massachusetts school. Lead was measured from teeth and the children were rated in eleven different categories: hyperactivity, distractibility, impulsiveness, independence, organizational skills, persistence, frustration level, daydreaming, following directions, sequencing, and overall classroom function. Lead levels directly correlated with all 11 categories. As stated in the article, "The frequency of non–adaptive classroom behavior increased in a dose-related fashion to dentine lead level." Significantly, a follow–up study 11 years later, found the subjects with higher lead levels to have: seven times less likelihood of graduating, six times more likelihood of having a reading disability, greater absenteeism, lower class rank, weaker language skills, slower reaction time, and poorer hand–eye coordination. Lead impairs neurotransmitter release and has been associated with reduced dopamine levels. Common sources of lead exposure include drinking water (contaminated from solder), ceramic glazes, art supplies, contaminated nutritional supplements, and old paint. Aluminum and cadmium toxicity have also been implicated in ADHD. Multiple heavy metals have a synergistic toxic effect, which is further amplified by nutrient deficiencies.

Toxin exposure (and possibly other contributing factors to ADHD) may occur as early in life as in the womb. Prenatal PCB exposure from contaminated fresh water fish was associated with children exhibiting lower cognitive function, particularly attention and memory, at age 11. PCBs and other toxins can impact the brain indirectly by damaging thyroid hormone metabolism. Thyroid hormones regulate neurotransmitter function and are more frequently low in ADHD children. 

I advocate a comprehensive evaluation and tailored nutritional program to address all the areas discussed in this article. This type of approach may obviate the need for medication. In cases where medication is used, nutrition can improve effectiveness and reduce the dosage required.