Does Maternal Vitamin D Affect Childhood ADHD?

Can ADHD Be Prevented?

vitamin dIf you are pregnant, or of childbearing age, should you be supplementing with vitamin D? Increasingly, the answer appears to be yes.

1) Based on blood 25-hydroxy vitamin D levels (considered the most accurate marker of vitamin D status):

    • 8-11% of pregnant women in the US are deficient in vitamin D (<30 nmol/L).
    • 25% of pregnant women have insufficient vitamin D status (30-49 nmol/L).

In short, that means around 1/3 of pregnant women in the US have insufficient or deficient levels of vitamin D. The effect of inadequate vitamin D during pregnancy is not just an academic question.

2) The Cochrane Collaboration (considered the gold standard for evidence-based medicine) has recently concluded that supplementation with vitamin D reduces the risk of significant complications during pregnancy.

3) Another recent study found that inadequate vitamin D status during pregnancy delayed several neurodevelopmental milestones in early childhood, including gross motor skills, fine motor skills, and social development.

If neurodevelopmental milestones are affected, what about ADHD? Here the evidence is not as clear. Some studies have concluded that vitamin D deficiency during pregnancy increases the risk of ADHD in the offspring. Other studies have concluded there is no effect of vitamin D deficiency on ADHD.

Why the discrepancy between studies?

  • Most of the previous studies have been small. Simply put, there were too few children in the study to make statistically reliable conclusions.
  • Most of the studies measured maternal 25-hydroxyvitamin D levels in the third trimester or in chord blood at birth. However, it is during early pregnancy that critical steps in the development of the nervous system take place.

Thus, there is a critical need for larger studies that measure maternal vitamin D status in the first trimester of pregnancy. This study (M Sucksdorff et al, Journal of the American Academy of Child & Adolescent Psychiatry, 2020, in press) was designed to fill that need.

How Was The Study Done?

Clinical StudyThis study compared 1,067 Finnish children born between 1998 and 1999 who were subsequently diagnosed with ADHD and 1,067 matched controls without ADHD. There were several reasons for choosing this experimental group.

  • Finland is among the northernmost European countries, so sun exposure during the winter is significantly less than for the United States and most other European countries. This time period also preceded the universal supplementation with vitamin D for pregnant women that was instituted in 2004.

Consequently, maternal 25-hydroxyvitamin D levels were significantly lower than in most other countries. This means that a significant percentage of pregnant women were deficient in vitamin D, something not seen in most other studies. For example:

    • 49% of pregnant women in Finland were deficient in vitamin D (25-hydoxyvitamin D <30 nmol/L) compared to 8-11% in the United States.
    • 33% of pregnant women in Finland had insufficient vitamin D status (25-hydroxyvitamin D 30-49.9 nmol/L) compared to 25% in the United States.
  • Finland, like many European countries, keeps detailed health records on its citizens. For example:
    • The Finnish Prenatal Study collected data, including maternal 25-hydroxyvitamin D levels during the first trimester), for all live births between 1991 and 2005.
    • The Care Register for Health Care recorded, among other things, all diagnoses of ADHD through 2011.

Thus, this study was ideally positioned to compare maternal 25-hydroxyvitamin D levels during the first trimester of pregnancy with a subsequent diagnosis of ADHD in the offspring. The long-term follow-up was important to this study because the average age of ADHD diagnosis was 7 years (range = 2-14 years).

Does Maternal Vitamin D Affect Childhood ADHD?

Child With ADHDThe answer to this question appears to be a clear, yes.

If you divide maternal vitamin D levels into quintiles:

  • Offspring of mothers in the lowest vitamin D quintile (25-hydroxyvitamin D of 7.5-21.9 nmol/L) were 53% more likely to develop ADHD than offspring of mothers in the highest vitamin D quintile (49.5-132.5 nmol/L).

When you divide maternal vitamin D levels by the standard designations of deficient (<30 nmol/L), insufficient (30-49.9 nmol/L), and sufficient (≥50 nmol/L):

  • Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

The authors concluded: “This is the first population-based study to demonstrate an association between low maternal vitamin D during the first trimester of pregnancy and an elevated risk for ADHD diagnosis in offspring. If these findings are replicated, they may have public health implications for vitamin D supplementation and perhaps changing lifestyle behaviors during pregnancy to ensure optimal maternal vitamin D levels.”

Can ADHD Be Prevented?

Child Raising HandI realize that this is an emotionally charged title. If you have a child with ADHD, the last thing I want is for you to feel guilty about something you may not have done. So, let me start by acknowledging that there are genetic and environmental risk factors for ADHD that you cannot control. That means you could have done everything right during pregnancy and still have a child who develops ADHD.

Having said that, let’s examine things that can be done to reduce the risk of giving birth to a child who will develop ADHD, starting with vitamin D. There are two aspects of this study that are important to keep in mind.

#1: The increased risk of giving birth to a child who develops ADHD was only seen for women who were vitamin D deficient. While vitamin D deficiency is only found in 8-11% of pregnant mothers in the United States, that is an average number. It is more useful to ask who is most likely to be vitamin D deficient in this country. For example:

  • Fatty fish and vitamin D-fortified dairy products are the most important food sources of vitamin D. Fatty fish are not everyone’s favorite and may be too expensive for those on a tight budget. Many people are lactose intolerant or avoid milk for other reasons. If you are not eating these foods, you may not be getting enough vitamin D from your diet. This is particularly true for vegans.
  • If you have darker colored skin, you may have trouble making enough vitamin D from sunlight. If you are also lactose intolerant, you are in double trouble with respect to vitamin D sufficiency.
  • Obesity affects the distribution of vitamin D in the body. So, if you are overweight, you may have low 25-hydroxyvitamin D levels in your blood.
  • The vitamin D RDA for pregnant and lactating women is 600 IU, but many multivitamin and prenatal supplements only provide 400 IU. If you are pregnant or of childbearing age, it is a good idea to look for a multivitamin or prenatal supplement that provides at least 600 IU, especially if you are in one of the high risk groups listed above.
  • Some experts recommend 2,000 to 4,000 IU of supplemental vitamin D. I would not recommend exceeding that amount without discussing it with your health care provider first.
  • Finally, for reasons we do not understand, some people have a difficult time converting vitamin D to the active 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D in their bodies. If you are pregnant or of childbearing age, it is a good idea to have your blood 25-hydroxyvitamin D levels determined and discuss with your health care provider how much vitamin D you should be taking. Many people need more than 600 IU to reach vitamin D sufficiency status.

#2: Maternal vitamin D deficiency has a relatively small effect (34%) on the risk of the offspring developing ADHD. That means assuring adequate vitamin D status during pregnancy should be part of a holistic approach for reducing ADHD risk. Other factors to consider are:

  • Low maternal folate and omega-3 status.
  • Smoking, drug, and alcohol use.
  • Obesity.
  • Sodas and highly processed foods.

Alone, each of these factors has a small and uncertain influence on the risk of your child developing ADHD. Together, they may play a significant role in determining your child’s risk of developing ADHD.

In closing, there are three take-home lessons I want to leave you with:

1) The first is that there is no “magic bullet”. There is no single action you can take during pregnancy that will dramatically reduce your risk of giving birth to a child who will develop ADHD. Improving your vitamin D, folate, and omega-3 status; avoiding cigarettes, drugs, and alcohol; achieving a healthy weight; and eating a healthy diet are all part of a holistic approach for reducing the risk of your child developing ADHD.

2) The second is that we should not think of these actions solely in terms of reducing ADHD risk. Each of these actions will lead to a healthier pregnancy and a healthier child in many other ways.

3) Finally, if you have a child with ADHD and would like to reduce the symptoms without drugs, I recommend this article.

The Bottom Line

A recent study looked at the correlation between maternal vitamin D status during the first trimester of pregnancy and the risk of ADHD in the offspring. The study found:

  • Offspring of mothers who were deficient in vitamin D were 34% more likely to develop ADHD than children of mothers with sufficient vitamin D status.

The authors concluded: “This is the first population-based study to demonstrate an association between low maternal vitamin D during the first trimester of pregnancy and an elevated risk for ADHD diagnosis in offspring. If these findings are replicated, they may have public health implications for vitamin D supplementation and perhaps changing lifestyle behaviors during pregnancy to ensure optimal maternal vitamin D levels.”

In the article above I discuss what this study means for you and other factors that increase the risk of giving birth to a child who will develop ADHD.

For more details read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

 

Do Omega-3 Supplements Reduce ADHD Symptoms?

Will The Omega-3 Controversy Continue?

adhd symptoms childrenThe prevalence of ADHD has increased dramatically in the last couple of decades. One study reported that the percentage of children diagnosed with ADHD has increased by 42% between 2003 and 2011. Another study reported an increase of 67% between 1997 and 2015. Currently, 10-12% of American schoolchildren are diagnosed with ADHD. That amounts to around 6 million children with ADHD, at a cost to taxpayers of over $45 billion.

An estimated 65% of children with ADHD are taking medications to control their symptoms. Unfortunately, those medications don’t work for 20-40% of patients with ADHD. Even worse, ADHD medications come with serious side effects like loss of appetite and delayed growth, sleep disorders, nausea & stomach pains, headaches, moodiness and irritability.

Even more worrisome is that many children say they “just don’t feel right” while they are on the drugs. Finally, there is the unintended message we are sending our children that drugs are the solution to their problems.

It is no wonder that millions of parents are looking for more natural solutions for their child’s ADHD. One of the most popular natural approaches is supplementation with omega-3s. But do omega-3 supplements work, or is this just another myth created by supplement companies to lighten your wallet?

The scientific evidence is conflicting. Some clinical studies support the efficacy of omega-3 supplements for reducing ADHD symptoms. Other studies claim they have no benefit.

In today’s issue of “Health Tips From The Professor”, I review a recent meta-analysis (JP-C Chang et al, Neuropsychopharmacology, 43: 534-545, 2018) that attempts to provide a definitive answer to this question.

How Was The Study Done?

Clinical StudyThis study was designed to answer three questions:

1)    Does omega-3 supplementation reduce ADHD symptoms?

2)    Does omega-3 supplementation improve cognitive skills in children with ADHD?

3)    Is there an association between omega-3 status and ADHD?

Previous meta-analyses on these topics had design flaws such as:

·       Including both children and adult subjects.

·       Including subjects with diagnosis other than ADHD.

·       Including trials that supplemented with vitamins and other nutrients in addition to omega-3s.

The authors of this study tried to avoid these limitations by using the following criteria for the studies that were included in their meta-analysis.

1)    The studies were randomized, double-blind, placebo-controlled trials of omega-3 supplementation with DHA and EPA alone or in combination.

2)    The participants were school-aged children (4-12 years) and adolescents (13-17 years) who had a diagnosis of ADHD.

3)    The study measured the effect of omega-3 supplementation on clinical symptoms of ADHD or measures of cognitive performance (omission errors, commission errors, forward memory, backward memory, and information processing).

4)    The studies were large enough to measure statistically significant differences.

5)    The studies were published in peer-reviewed journals.

With these criteria there were:

·       Seven studies with 534 children looking at the effect of omega-3 supplementation on ADHD symptoms.

·       Three studies with 214 children looking at the effect of omega-3 supplementation on cognitive performance.

·       Twenty studies with 1276 children looking at the association between omega-3 status and ADHD.

Do Omega-3 Supplements Reduce ADHD Symptoms?

adhd symptoms omega-3sThe results of this meta-analysis were as follows:

1)    Omega-3 supplementation significantly reduced ADHD symptoms reported by parents.

2)    Omega-3 supplementation significantly improved cognitive measures associated with attention span (omission and commission errors). [Note: Omission errors consist of leaving important information out of an answer. Commission errors consist of including incorrect information in an answer.]

·       Omega-3 supplementation did not improve cognitive measures associated with memory and information processing. This has also been reported in most previous studies.

·       The best way to think of this is that children with ADHD are fully capable of learning their schoolwork. However, they may have trouble demonstrating what they have learned on exams because of omission and commission errors.

·       In this context, omega-3 supplementation may help them perform better on exams and reduce test-taking anxiety.

3)    For hyperactivity, only studies with EPA dosages of 500 mg per day or greater showed a significant reduction in symptoms.

4)    Children diagnosed with ADHD have lower levels of DHA, EPA, and total omega-3s.

The authors concluded: “In summary, there is evidence that omega-3 supplementation … improves clinical symptoms and cognitive performances in children and adolescents with ADHD, and that these youth have a deficiency in omega-3 levels. Our findings provide further support to the rationale for using omega-3s as a treatment option for ADHD.”

They also said: “Our paper shows that EPA supplementation dosage >500 mg should be considered when treating youth with ADHD, especially those with predominantly hyperactivity/impulsivity presentation.”

Will The Omega-3 Controversy Continue?

ArgumentThis is an excellent study, but it is unlikely to be the final word on this subject. That is because there is a fundamental flaw in all previous studies on this important subject, including the ones included in this meta-analysis.

In the words of the authors: “In terms of ‘personalized medicine’, it is tempting to speculate that a subpopulation of youth with ADHD and low levels of omega-3s may respond better to omega-3 supplementation, but there are no studies to date attempting this approach.”

Until studies of omega-3 supplementation and ADHD symptoms include measures of omega-3 status before and after supplementation, those studies are likely to continue giving conflicting results. That is because:

·       If most of the children in the study have low omega-3 status, we are likely to see a positive effect of omega-3 supplementation on ADHD symptoms.

·       If most of the children in the study have high omega-3 status, we are likely to see a negative effect of omega-3 supplementation on ADHD symptoms.

What Does This Study Mean For You?

confusionWhile this study is unlikely to end the omega-3 controversy, it is a very well-designed study that combines the results of multiple double-blind, placebo-controlled clinical trials. In short, it is a very strong study.

Omega-3s have no side effects and multiple health benefits. If your child suffers from ADHD, omega-3 supplementation is worth a try.

However, we need to keep omega-3 supplementation in perspective:

·       Not every child with ADHD will respond to omega-3 supplementation.

·       Omega-3s alone are likely to reduce, but not eliminate, the symptoms.

·       There are other natural approaches that should be considered.

You will find details on omega-3s and other natural approaches for reducing ADHD symptoms in an earlier issue of “Health Tips From The Professor”.

The Bottom Line

A recent meta-analysis looked at the effect of omega-3 supplementatation on ADHD symptoms. Here is a brief summary of the data:

1)    Omega-3 supplementation significantly reduced ADHD symptoms reported by parents.

2)    Omega-3 supplementation significantly improved cognitive measures associated with attention span (omission and commission errors). [Note: Omission errors consist of leaving important information out of an answer. Commission errors consist of including incorrect information in an answer.]

·       Omega-3 supplementation did not improve cognitive measures associated with memory and information processing. This has also been reported in most previous studies.

·       The best way to think of this is that children with ADHD are fully capable of learning their schoolwork. However, they may have trouble demonstrating what they have learned on exams because of omission and commission errors.

·       In this context, omega-3 supplementation may help them perform better on exams and reduce test-taking anxiety.

3)    For hyperactivity, only studies with EPA dosages of 500 mg per day or greater showed a significant reduction in symptoms.

4)    Children diagnosed with ADHD have lower levels of DHA, EPA, and total omega-3s.

The authors concluded: “In summary, there is evidence that omega-3 supplementation … improves clinical symptoms and cognitive performances in children and adolescents with ADHD, and that these youth have a deficiency in omega-3 levels. Our findings provide further support to the rationale for using omega-3s as a treatment option for ADHD.”

They also said: “Our paper shows that EPA supplementation dosage >500 mg should be considered when treating youth with ADHD, especially those with predominantly hyperactivity/impulsivity presentation.”

For more details on the study and a perspective on omega-3 supplementation compared to other natural approaches for reducing ADHD symptoms, read the article above.

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Are ADHD Symptoms Reduced by Omega-3s?

Can Natural Approaches Cure ADHD?

Author: Dr. Stephen Chaney

 

adhd symptoms childrenYou keep seeing headlines saying that omega-3 fatty acids can help children with ADHD. But your pediatrician doesn’t recommend them. Why not? Is the story about omega-3s helping with ADHD symptoms just another myth created by supplement companies wanting to lighten your wallet? Or, is your doctor not keeping up with the latest scientific advances? As usual, the truth lies somewhere in between.

This week I will discuss the latest study (J.P-C. Chang et al, Neuropyschopharmacology, 43: 534-545, 2018) on omega-3s and ADHD symptoms. It provides an excellent update on the role of omega-3s in reducing ADHD symptoms.

 

How Was The Study Done?

adhd symptoms studyThe study was a meta-analysis. Meta-analyses combine the data from multiple studies. Their strength comes from the fact that they include data from subjects of different backgrounds and ethnicity. However, a meta-analysis can never be stronger than the studies it includes in its analysis. Simply put, if it combines data from poorly designed studies, it is no better than the weakest study.

The problem is that there have been a lot of poorly designed studies in this area of research. Some studies have included both children and adults. Others included subjects with psychiatric diagnoses other than ADHD. Still others combined omega-3 supplementation with other vitamins and nutrients. Finally, some used inadequate measures of ADHD symptoms and cognitive function. Because the design of previous studies has been so varied, the results have been conflicting. Some studies have found that omega-3 supplementation reduced ADHD symptoms. Others found no benefit.

Because of the confusion arising from poorly designed studies, the authors of this study applied very rigorous criteria in selecting the studies to be included in their meta-analysis. Their criteria were:

  • The studies were randomized, double-blind, placebo-controlled trials of mega-3 supplementation with DHA or EPA alone or in combination.
  • Participants were school-aged children (4-12 years) and adolescents (13-17 years) who had a diagnosis of ADHD.
  • The study measured clinical symptoms of ADHD as reported by parents. Some also included reports by teachers. When cognitive data were included, the studies relied on well-established cognitive tests.
  • The data allowed a calculation of effect size (this is a statistical requirement that simply says the quality of the data were good enough to reliably calculate the difference between the supplemented and control groups).
  • The publications were in peer reviewed journals.

They ended up with seven studies with a total of 534 subjects (318 received omega-3s and 216 received a placebo).

They also performed a separate metanalysis of studies that have measured omega-3 levels in school-aged children and adolescents who had been diagnosed with ADHD. The criteria for inclusion in this metanalysis were similarly rigorous. They ended up including nine studies totaling 558 subjects, 297 with ADHD and 261 controls in this meta-analysis.

 

Do Omega-3s Reduce ADHD Symptoms?

adhd symptoms omega-3sThe results from the first meta-analysis were:

  • Omega-3 supplementation significantly improved parental reports of total ADHD symptoms scores as well as scores of inattention and hyperactivity.
  • When the children were given cognitive performance tests, the omega-3 supplemented group performed better than the placebo group when tested for omission errors (for example, a number or word left out in a memory test) and commission errors (an incorrect number or word in a memory test).
  • A dose of EPA + DHA of 500 mg/day or greater appeared to be optimal.

The results from the second meta-analysis were:

  • Children and adolescents with ADHD had significantly lower levels of DHA, EPA, and total omega-3s in their red blood cells (a good measure of omega-3 status) than controls.

The authors concluded: “In summary, there is evidence that omega-3 supplementation improves clinical symptoms and cognitive performances in children and adolescents with ADHD, and that these youth have a deficiency of omega-3 levels. Our findings provide further support to the rationale for using omega-3s as a treatment option for ADHD.”

The authors went on to say: “In the context of ‘personalized medicine,’ it is tempting to speculate that a subpopulation of youth with ADHD and low levels of omega-3s may respond better to omega-3 supplementation, but there are no studies to date attempting this stratification approach [looking at the effect of omega-3 supplementation in the subpopulation with both ADHD and omega-3 deficiency]…Therefore, stratification of ADHD children by omega-3 levels…could be one approach to optimize the therapeutic effects of omega-3 supplementation.”

Basically, they are suggesting that the benefits of omega-3 supplementation are likely to be greatest for those children with ADHD who are also omega-3 deficient. They are also saying that future studies should measure omega-3 status before and after supplementation so that the true benefit of omega-3 supplementation can be determined. I agree

 

What Does This Mean For You?

adhd symptoms youthThis study was very well done. By including only the best designed studies in their meta-analysis, the authors have provided good evidence that omega-3s can be of benefit in reducing ADHD symptoms. The authors also pointed out that low-dose omega-3 supplementation is virtually free of side effects. Thus, this is an option that should be tried first, before considering medications to control ADHD symptoms.

On the other hand, I wouldn’t expect miracles. This was not a huge effect. Not all the ADHD symptoms improved with omega-3 supplementation. Teacher’s reports did not show the same benefits as parent’s reports.

There are two ways to interpret the limitations of omega-3 benefits seen in this meta-analysis.

  • Clinical studies report the average results for all the children in the study. Your child may not be average. If your child doesn’t like fish, especially the oil, cold-water fish that are rich in omega-3s, they may experience a greater benefit from omega-3 supplementation.
  • The benefit of omega-3s seen in this meta-analysis is just one facet of a holistic, natural approach for controlling ADHD without drugs. One of the best reviews on natural approaches for controlling ADHD was written by two pediatricians with years of experience dealing with ADHD. I wrote about their review in a previous issue, adhd diet vs medication, of “Health Tips From the Professor”. You should check it out. There was a lot of wisdom in their advice.

 

The Bottom Line

 

  • A recent meta-analysis has reported that omega-3 supplementation improves clinical symptoms and cognitive performances in children and adolescents with ADHD.
  • The optimal dose appeared to be 500 mg/day or above.
  • The authors also reported that children with ADHD were more likely to be omega-3 deficient than children without ADHD and suggested that omega-3 supplementation is most likely to be effective for those children who are omega-3 deficient.
  • The authors also pointed out that low-dose omega-3 supplementation had negligible side-effects, so it should be tried before the child is put on medication.
  • Omega-3s are just one facet of a holistic, natural approach for reducing ADHD symptoms.

For more details, read the article above.

 

These statements have not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure or prevent any disease.

Health Tips From The Professor