Attention Deficit Hyperactivity Disorder (ADHD) is a condition that affects behaviour and is characterised by inattentiveness, impulsivity and distractibility. For many children, ADHD co-exists with some form of anxiety.
The nutritional consequences of ADHD are far ranging and there is a huge amount of information out there making it difficult to separate fact from fiction. To make it more complicated, the issues vary according to the individual, as well as their environment and family circumstances. As regulated healthcare professionals, Dietitians must keep up to date with the latest evidence and our role is to tailor this to your personal circumstances. In this post I have tried to cover some general tips on the topics that frequently arise in my practice.
Mealtimes and eating out.
Distractibility can be a real problem for some children, making sitting at a table for a family meal difficult and eating at a restaurant a stressful experience. Observe your child really carefully to work out what conditions help them remain calm and what factors cause distraction during a meal. This will be different for every child, but working this out may help you alter the environment to meet their needs. Avoid comparing yourself to other families or social expectations as your family has its own specific needs.
Anxieties around picky eating
It is not uncommon for children to go through stages of picky eating, but these can be particularly difficult when behaviour is challenging to manage. To avoid creating a battleground over food, stick to a three meal a day and three snack a day routine. Keep mealtimes to 30 minutes and present and clear away uneaten food without judgement. Keep rewards for good behaviour unrelated to food to prevent ‘treat’ foods having emotional significance. Similarly with-holding food to manage behaviour is likely to raise tensions further and may result in inadequate nutrition.
Medications
Loss of appetite is a common side effect of some of the drugs used to treat ADHD. For those who experience this, provide a good meal before taking medication and after it has worn off in the evening. During the rest of the day, your child will need small regular snacks to keep their blood sugars and brain chemicals stable.
Planning and organisation of meals
ADHD is associated with difficulty managing executive functions such as planning and organisation, skills that are key for shopping, cooking and eating well. Many adults and older children with ADHD show greater reliance on less healthy convenience foods and take-aways. As children grow and become more independent it is important to think ahead with strategies to plan meals to remain healthy.
Foods that may make symptoms worse
You may read about foods that are said to make ADHD behaviours worse, such as sugar, artificial sweeteners and and some colourants and preservatives [1].
The science doesn’t support the theory that sugar or artificial sweeteners make ADHD symptoms worse. That said, we know that limiting free sugar can prevent weight gain and tooth decay. Government guidelines recommend all children aged 4 to 6 years old should have no more than 5 sugar cubes and children 7 to 10 years should have no more that 6 sugar cubes of free sugar a day [2].
Recent research shows that there is a possible link between some artificial additives and hyperactivity, however this is no worse in ADHD than the general population. The British Food Standards Agency advises parents to consider avoiding a list of 7 additives if you think this may be an issue. If you think there may be a link, it is a good idea to keep a food and symptom diary.
Treatment with elimination diets has shown some limited success and is based on the idea that ADHD behaviours may be triggered by food sensitivity as an immune reaction to food [3-4]. If you do try a restrictive diet it is important you do this under medical or dietetic advice for a limited time only to ensure growth and nutritional adequacy is not affected.
Foods that improve symptoms
Additional zinc, vitamins A and C and fish oil supplementation have been studied to see if they improve symptoms however there is little robust evidence to support this [1,5]. A dietitian can help ensure your child has a balanced diet and receives all the nutrition required from food sources.
There is building evidence that the quality of our overall diet is not only critical for our physical health, but has significant effects on our mental wellbeing and mood. Of particular interest is the relationship between the food we eat and the bacteria in our gut, or the microbiome. On a mechanistic level there is a lot of evidence that complex communication occurs between the microbiome, our gut and our brain which alters our mood and our behaviour [6]. Improving our diet quality has been shown to be an effective treatment for mental health conditions [7] and may be a useful adjunct to manage anxiety.
The experience of ADHD is different for every individual and is dependent on the environment in which we live. If you would like tailored nutrition advice for ADHD, please get in touch. After a full assessment of your needs, I can help make a personalised plan and provide ongoing support as needed.
References
1. Ritter MJH et al. (2014) Diet in the treatment of ADHD in children - A systematic Review of the Literature; June 2014 Nordic Journal of Psychiatry 69(1):1-18
3 Sonuga-Barke EJ et al (2013), Nonpharmacological interven- tions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 2013;170(3): 275–89.]
4 Pelsser LM et al. Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Lancet 2011;377(9764):494–503.]
5 Gillies D et al. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev 2021;7;CD007986
6 Dam SA et al. (2019) The Role of the Gut-Brain Axis in Attention-Deficit/Hyperactivity Disorder. Gastroenterol Clin North Am. Sep;48(3):407-431. doi: 10.1016/j.gtc.2019.05.001. Epub 2019 Jul 2. PMID: 31383279
7 Jacka et al. (2017) A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial) BMC Medicine 15:23