Science behind Nutraceuticals

ADHD

In a nutshell

  • For children with ADHD specific fatty acid products may be recommended as supportive treatment.
  • In particular, the omega-3 fatty acid EPA and the omega-6 fatty acid GLA seem to play an important role what should be considered when choosing a suitable product.
  • In addition, one should take care of an appropriate dosage (not less than 1g fish oil) and the general dietary recommendations.

What is ADHD?

ADHD is short for attention deficit hyperactivity disorder. This entails a mental disorder that manifests itself by problems with attention, impulsivity and hyperactivity starting in childhood.
The best known and most common measure for the treatment of ADHD is through treatment with stimulant medication.

Additional therapeutic options also exist which should be applied within the framework of a multimodal approach.
Unfortunately, these are often not as effective as medication. On the other hand, many reservations have been expressed by the affected families concerning drug therapy. Alternatives or supportive measures are therefore welcomed.

This is where administering nutraceuticals in the form of fatty acid mixtures has proven to be significantly effective for the treatment of ADHD, as the literature  supports.
However, the effects are not as strong as with drugs, so these products should especially be used as a complementary measure in order to, for example, reduce the dose of stimulants.

Science results

Summary of research results

  • In two important meta-analyses (details..), a significant treatment effect of polyunsaturated fatty acids (PUFAs) in children with ADHD has been demonstrated. The results of one of the meta-analyses, which used a very strict method, indicate a smaller effect size than the Yale University meta-analysis. The effect size, which was between 0.16 und 0.31, depending on the method, is relatively low in comparison to the effect size of established pharmacotherapies (effect size about 0.9). Therefore nutraceutical intervention is not recommended as a substitute for pharmacotherapy, but as a support for other measures.
  • In particular, the omega-3 fatty acid eicosapentaenoic acid (EPA), and not docosahexaenoic acid (DHA) seems to be responsible for the positive effect. In addition, the omega-6 fatty acid gamma-linolenic acid (GLA) seems to play a role.

Practical relevance

  • Recommendation: based on good scientific data, the use of PUFAs in ADHD in children is recommended. This is especially due also to the fact that these fatty acids have practically no side effects, and in addition provide other positive effects.
  • Application: fatty acid products are not a substitute for pharmacotherapies. However, they are very useful as supportive treatment and may be able to contribute to the dose reduction of medication (such an attempt should be made no earlier than three months after initiation of fatty acid administering and under medical supervision).
  • Product composition: The fatty acid composition should be considered when choosing a suitable product: the proportion of EPA should be higher than that of DHA, and should also  contain GLA. In addition, attention should be paid to good quality, especially that the product is free of contamination (e.g. mercury).
  • Dose: the dose should not be less than 1g fish oil (better yet 2g).
  • General note: care should be taken to ensure that a child's diet conforms to general dietary recommendations.

Scientific Literature

Challenges
One is confronted with several challenges in the assessment of the available science:

  • Diagnosis and therapy control: in some of the studies the diagnosis was not clear. On the other hand the rating of the effectiveness of an intervention presents the challenge that where, for instance, parents as close caregivers are responsible for it (parental rating), there is a danger of not getting an objective assessment. Therefore, some authors advocate for a rating by non-involved persons.
  • Low number of subjects: many of the studies have only a relatively small number of subjects, limiting the reliability of the study. For this reason, meta-analyses, where these studies can be evaluated together, are especially valuable (see below).
  • Study design: it was (and is) often difficult to implement a complete placebo-controlled study design.

Selection of Literature
Especially due to the fact of low numbers of subjects in the individual studies on this issue, the use of meta-analyses is particularly important.
Currently there are two such meta-analyses, which were used as the basis of our assessment. Both publications have been published in very highly respected journals:

1.    The meta-analysis of the prestigious Yale University from October 2011:
Bloch MH, Qawasmi A. Omega-3 Fatty Acid Supplementation for the Treatment of Children With Attention-Deficit/Hyperactivity Disorder Symptomatology: Systematic Review and Meta-Analysis. Journal of the American Academy of Child & Adolescent Psychiatry, Volume 50, Issue 10 , Pages 991-1000, October 2011

2.    The meta-analysis of the European ADHD Guidelines Group (EAGG) from March 2013:
Sonuga-Barke EJS et al. Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments. The American Journal of Psychiatry, Volume 170, No. 3, Pages 275-289

More systematic reviews on this subject, some of which came to different conclusions, were not considered because the value, and thus the validity of the meta-analyses is significantly higher and more reliable.

Further References
Commentary with practical applications of the meta-analysis of Yale:
Arnold LE. Fish Oil Is Not Snake Oil. Journal of the American Academy of Child & Adolescent Psychiatry, Volume 50, Issue 10 , Pages 969-971, October 2011