Diet, ASD & ADHD: Is there a diet for ASD / ADHD?

Transcription

1 Diet, ASD & ADHD: Is there a diet for ASD / ADHD? Dave Rex, Specialist Dietitian for Health Promoting schools and children with ASD, NHS Highland David.Rex2@nhs.net

2 Does Iron deficiency lead to anaemia? Scientific evidence what does this mean for nutrition? Nutrition science Based on the assumption that food choices affect health and wellbeing Which food choices affect which aspects of health and wellbeing is less clear Does dietary cholesterol cause heart disease? Does salt raise blood pressure?

3 Medicine and precautionary principle Medical interventions can be harmful Examples include drugs and surgery 1. If there is significant doubt about safety, it may be better to do nothing 2. If there is significant doubt about efficacy, it may not be worth it 3. We also have limited resources in the NHS This is why we should consider a Levels of evidence approach

4 Diet, Health Promotion and Levels of Evidence We promote dietary changes that we believe to be good for health and wellbeing The Eatwell Plate is a best guess at a practical diet with the best potential for health and wellbeing All the research that underpins this is very uncertain but. We have to eat!

5 Research and Diet Blinded trials are easier for pills than foods RCT s on diet are less attractive to corporate funding RCT s that produce off-message results are not published Cannot afford to ignore population studies Cannot regard population studies are more than correlation

6 Hierarchy of commercial research incentives and ease of blinded study design Ritilin>Benecol>fish oil>fish>apples Conclusion: Healthy fresh foods are poor commodities Good commodities make poor foods

7 Go cautiously Is the case for nutrition exaggerated? Is there a lot of bad nutrition science? Is the food industry another vested interest? Yes, Yes and Yes!

8 What dietary changes can help children with ASD, ADHD and related disorders? Polarised views evidence is often exaggerated or unfairly dismissed Need to look for the best available evidence Give families tools to make informed choice

9 Dietary Interventions in ASD - An Iceberg in Turbulent Waters Will it Help? Is it acceptable and palatable? Is it safe? Is there reliable, unbiased, information and support? Is it practical? Fish oil Gluten /casein free Multivit, mineral supplements Food Additives Can I afford it? B6 plus Mg Zinc Sulphation: phenols / amines Enzyme supplements Specific carbohydrate diet Pro and prebiotics Methyl B12

10 Characteristics of useful interventions Is it likely to make any difference? Is it affordable? Will the diet still be palatable? How much will it substantially disrupt the rest of the diet? Will it make the diet deficient in something important? Does the diet seem obviously very different?

11 and avoid any food that provokes an extreme or behavioural SIGN guidelines on ADHD Nutrition interventions Acknowledges research on zinc, fatty acids, Iron and food additives. No recommendation can be made about fatty acid supplements or Zinc. Iron status should be considered when taking a history, with serum Iron and Ferritin measured and treatment with supplements if appropriate. Parents and carers should take reasonable steps to reduce intake of food additives such as artificial colours and benzoate preservatives,

12 SIGN guidelines for ASD Food selectivity is not acknowledged as a particular problem B6 and Magnesium are not recommended Gluten / casein free diets not recommended Iron, Zinc, Food additives, omega 3 fats are not mentioned

13 SIGN and NICE Appropriate approach for nutrition? The rules applied are inappropriately narrow for nutrition We need to avoid both paternalistic and consumerist models of healthcare My 5 rules apply a healthy dose of common sense These rules are less prone to corporate capture They enable food and diet to be considered not just supplements and drugs They help facilitate a dialogue that enables joint decision making between client (or family) and practitioner

14 5 steps for a new Gold standard for dietary evidence 1. Is there evidence of marginal or excessive intakes at the population level? 2. Are there plausible mechanisms through which the nutrient, food or diet might help? 3. Is the food, nutrient, or diet broadly consistent with healthy eating messages? 4. Are there populations who consume this nutrient, food or diet at this level, without obvious harmful effects? 5. Is there some evidence from clinical trials in favour of the proposed nutrient, food or diet?

15 European 5-a-day Championship - latest score!!! Greece 9 Scotland 3

16 The best available evidence Food additives: for... McCann et al. (2007) The Lancet. Large study involving 300 children without ADHD. Design: placebo controlled double blind cross-over trial testing benzoate preservatives and azo food dyes. Outcome: Statistically significant increase in hyperactivity and inattention scores. Effects could be amplified by consumption of Aspartame and flavour enhancers (see Howard et. al (2006)) Azo dyes can reduce Zinc status in children with ADHD and have no effect on the Zinc status of those without ADHD (see Ward et. al (1997)

17 Neurite outgrowth image analysis Howard et. al Differentiating Nb2a cells A. in the absence of additive (control) B. 1µM L-glutamic acid to produce 20% neurite inhibition C. 0.1nM BB to produce 20 % neurite inhibition D. Mixture of BB and L-glutamic acid each at 50% of the above concentrations A B C D Implicated additives: Aspartame, MSG, artificial food dyes

18 Vitamins and Minerals - Iron Iron from all sources (including supplements) % of children of all ages with intakes below RNI and LRNI % < RNI % < LRNI <4 >4 Boys Girls Boys Girls Boys Girls Boys Girls Age 4-6 Age 7-10 Age Age * Gregory et al National Diet and Nutrition Surveys, HMSO

19 Iron and cognition Iron plays a vital role in mood and cognition Low Ferritin stores may be more common in children with ADHD than those without Low Ferritin stores are common in children with a poor diet Severity of symptoms may correlate with Ferritin levels Case study of ADHD symptoms improving in child treated with Iron

20 Vitamins and Minerals - Zinc Zinc from all sources (including supplements) % of children of all ages with intakes below RNI and LRNI % < RNI % < LRNI <4 >4 Boys Girls Boys Girls Boys Girls Boys Girls Age 4-6 Age 7-10 Age Age * Gregory et al National Diet and Nutrition Surveys, HMSO

21 The best available evidence for... Zinc: Stimulant medication may work better in children with good Zinc status Poor Zinc status is more common in ADHD Zinc supplements plus stimulants may be better than placebo plus stimulants Zinc supplements may help when given on their own

22 Oily fish and omega 3 fatty acids

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24 World Intakes of Omega-3s

25 Teacher-rated ADHD symptoms Reduction in ADHD-related Symptoms DSM Combined-type DSM Hyperactivity DSM Inattention Conners Global Index CG Emotional Lability CG Restless-Impulsive Conners Index Social Problems Perfectionism Anxiety Hyperactivity Cognitive Problems Opposition Placebo (N=52) Active (N=50) Treatment Effect Size (Mean change 0-3m / Pooled Baseline SD)

26 Seafood Consumption and Cardiovascular Mortality among Males by Country WHO Mortality data, age adjusted, and WHO-FAO disappearance data for seafood: Ferguson, Hibbeln, et al unpublished 1000 Bulgaria r = r 2 = 0.72 p < Romania Cardiovascular mortality (# per 100,000) Hungary Czechoslovakia Argentina China Austria Germany Netherlands Switzerland Poland Ireland NZ UK Denmark USA Greece Belgium Sweden Australia Israel Canada Italy France Finland Spain Norway Korea Portugal Japan Apparent seafood consumption (lbs/person/y)

27 Fish Consumption and Major Depression Annual Prevalence by Country 6% Major Depression, Annual prevalence, (rate /100 persons) 5% 4% 3% 2% 1% New Zealand (5.8%) W. Germany (5.0%) United States (3.0%) Canada (5.2%) France (4.5%) Puerto Rico (3.0%) Taiwan (0.8%) Korea (2.3%) r =-0.84 p <0.005 Japan (0.12%) Apparent Fish Consumption (lbs./ person/year) Hibbeln, The Lancet 1998;351;1213

28 Fish consumption during pregnancy and children s IQ at 8 years of age Data from the ALSPAC Birth cohort study (t al 2006)

29 Fish consumption during pregnancy and abnormally poor prosocial skills at 8 yrs Data from the ALSPAC Birth cohort study (Hibbeln et al 2006)

30 Worthwhile Dietary Interventions Restriction of soft drinks and confectionery Assessment and correction of poor Iron status Assessment and correction of poor Zinc status Fish / omega 3 supplements Use of multi-vit/mineral supplements if diet poor Vitamin D supplementation Promotion of fruit and vegetables Well supervised trial exclusion diets

31 Zinc and other minerals Practical Implications Red meat and fish are good sources of Zinc Alcohol contributes to Zinc depletion Iron is also important for brain function Iron in lean beef, lamb and venison well absorbed Chicken nuggets - may contribute to Iron deficiency Magnesium may be important too the mineral that makes your greens green!

32 Food Additives Practical Implications Additive laden soft drinks have been mostly removed by Scottish schools Drinks sweetened with added sugar and or artificial sweeteners make educating the palate more difficult Diluting juices are not always better than fizzy drinks Confectionery and sugary drinks that are free from additives are still high in sugar, and provide empty calories Avoiding food additives is no guarantee of a healthy diet Some children are more affected by food additives than others

33 Fish Practical Implications Canned tuna is popular, but not rich in omega 3 Salmon kebabs and nibbles on school menu Selective eaters with ASD can learn to love mackerel! Should message be Eat oily fish instead of lean? Some popular supplements provides very little EPA Does your fish come from a sustainable source?

34 Also... Intolerances to natural foods can also be important: Examples: Salicylates, Phenols, Amines, Carotenoids, Gluten, Casein Risk: Could lead to exclusion of important nutrients if done without supervision Conclusion:

35 Milk Protein Intolerance Consider milk intolerance in the family Eczema and bowel symptoms 19 out of 24 successful with goat, sheep, buffalo products Better taste and for cooking than soya Most OK with butter Rice, oat and soya alternatives Depends on adequate protein elsewhere in diet

36 Summary 10 steps to the right diet for children with ASD / ADHD 1. Eat regularly 2. Insist on breakfast 3. Additive audit 4. Eat oily fish or take a supplement 5. Consider vitamin D supplement 6. Eat at least 5 portions fruit and veg a day 7. Eat beef, lamb or venison twice a week for Iron 8. Have pure fruit juice with toast or breakfast cereal 9. Check Iron and ferritin if fruit/veg/red meat intake is poor 10. Consider sensitivity to natural foods, but seek advice

37 Summary Slide 1 There is no single right diet for ADHD or ASD There are aspects of diet that are particularly important for the brain Many diets are low in nutrients that play an important role in brain function There are many vulnerable children whose mood, behaviour and concentration are markedly affected by diet, and some of those have an ADHD or ASD diagnosis

38 Summary Slide 2 There is significant overlap between general healthy eating advice, and specific advice for optimal mood and attention of vulnerable children This overlap represents a space where responsible Dietitians should practice