Fish Oil and ADHD: The New York Times Runs a Balanced Report

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Fish Oil and ADHD: The New York Times Runs a Balanced Report

 

Experts point to the strong potential and need for more research; Basic

biology and some clinical studies offer hope

 

by Craig Weatherby

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An article titled " Feeling Good About Fish Oil " appeared last week in

The New York Times.

Several customers wrote to ask our opinion, so we decided to offer our

take on the article.

The report began with the story of a 4-year-old boy who began grinding

his teeth at night and displaying obsessive behaviors to an " unnerving "

degree.

The boy's pediatrician - Sandy Newmark, M.D., of Tucson, Arizona

- recommended two supplements.

The first was inositol: a body chemical required for various nervous

system functions, low levels of which are associated with depression and

obsessive-compulsive disorders.

Dr. Newmark also recommended a daily teaspoon of fish oil, for its

omega-3 fatty acids. (One teaspoon holds about 4,000 mg of fish oil.)

Key Points

- The New York Times reports that omega-3 fish oil shows promise in

attention/behavior disorders.

- Basic science supports the wisdom of trying fish oil in kids with

ADHD, under a doctor's supervision.

- More clinical research is needed to test the efficiacy of fish oil;

Safety is not in dispute.

- Efficacy of fish oil may vary depending on the reasons for an

individual child's problems.

The Times article quoted the boy's mother, Melissa Jump: " I saw a

difference within a week. He's more chill; he can roll with things more.

He asks about his blanket every once in a while, but it's no big deal. "

As Dr. Newmark says on his Web site, " ... we recognize that there are

times when stimulants such as Ritalin are necessary. Even in those

cases, alternative ADHD approaches may support the child and minimize

the dose of medication or side-effects. "

(Coincidentally, Vital Choice supports the Weil Foundation, which in

turn supports the University of Arizona's Program in Integrative

Medicine, where Dr. Newmark completed a two-year fellowship under

program founder Andrew Weil, M.D.)

Signs of promise within a clouded picture As Times reporter Roni Caryn

Rabin wrote, " ... many parents concerned about the side effects of

conventional medications are turning to fish oil first, to treat not

just mood disorders but also a variety of learning and developmental

problems, including autism, dyslexia and, most notably, attention

deficit hyperactivity disorder, or A.D.H.D. "

She spoke with Dr. Lawrence D. Rosen, who practices integrative medicine

in Oradell, New Jersey, who told her that some children do well on fish

oil and other nutritional supplements plus educational and behavioral

aid, without medication.

But, as he told Ms. Rabin, " These are generally not the kids who have

severe behavioral difficulties or incredible hyperactivity. "

Neither of the other two doctors interviewed expected that by itself,

taking fish oil is likely to prove a consistently effective stand-alone

treatment for ADHD, given individual variations in the condition's

severity and possible causes.

But as every literature review finds, there's promising (albeit mixed)

clinical evidence, and plausible biological reasons why omega-3s in fish

oil might help affected kids' brains function better.

The Times story featured these points about fish oil for ADHD.

- The full value of fish oil for ADHD and related conditions remains

uncertain, due to a lack of reliable clinical evidence.

- Fish oil is safe, and not known to exacerbate any ADHD-type disorders.

- Fish oil enjoys fast-growing popularity among parents of children

plagued by behavior and attention problems. And recent scientific review

papers on the subject agree that we need to know much more about the

interactions between dietary omega-3s and genetic, nutritional, or

environmental variables.

The small, weak, inconclusive body of clinical ADHD research on omega-3s

is typical of nutrition-disease interaction research, almost all of

which is designed and performed at universities to answer basic biology

questions.

Generally speaking, only large pharmaceutical companies can afford the

$200 million-plus process of proving the efficacy and safety of a

proposed treatment to the FDA ... whose approval is required to make and

advertise enormously profitable disease-treatment claims.

Inclusion of Mayo clinical trial misleads The Times article mentioned

both of the above studies, but added that a four-month Mayo Clinic trial

involving 63 children found no decrease in ADHD symptoms after four

months of omega-3 DHA supplementation therapy (345 mg per day).

However, the Times article failed to note that, as the

researchers wrote, the kids in the Mayo Clinic trial were " ... all

receiving effective maintenance therapy with stimulant

medication. "

In other words, the children had been taking Ritalin-type drugs for some

time, which had already reduced their symptoms substantially (Voigt RG

et al. 2001).

Thus, the Times article leaves the impression that the Mayo Clinic trial

was a meaningful test of the effects of omega-3s in ADHD. In fact, all

the results showed was that omega-3 DHA did not reduce the kids'

symptoms further.

While this is nice to know, it's not terribly surprising or helpful, nor

does it mean that the supplemental DHA given the children did not

improve mental functions that were not measured in the trial.

Basic science supports an optimistic stance Of the two vital omega-3s in

fish oil - DHA and EPA - the one most closely associated with brain

function is DHA.

In fact, DHA constitutes about 15 percent of the total weight of human

brains (20 percent of infants' brains), and about 60 percent of the

brain's cell membranes.

The DHA in cell membranes accounts for their unique fluidity.

And both omega-3s exert an astonishing range of influences, including

regulation of neurotransmitters and gene transcription. They also serve

as the precursors of the anti-inflammatory immune-system agent called

autocoids, including some recently discovered compounds (neuroprotectins

and resolvins) that may have particular importance to brain function.

In the developing brain, DHA stimulates nerve growth, and it accumulates

preferentially in areas of high growth and activity (e.g., synaptic cell

membranes, synaptic vesicles, astrocytes, myelin, and mitochondrial

membranes).

And low levels of omega-3 DHA in children are linked strongly to

increased risk of attention-deficit/hyperactivity problems.

Given its equally wide range of influences, there are good reasons to

suspect that omega-3 EPA might positively influence attention

deficit/hyperactivity tendencies in distinct ways as well.

Two recent studies support call for more research Three years ago, we

reported the results of a British clinical study that tested the effects

of a supplement containing 80 percent fish oil in 117 children suffering

from an attention-behavior disorder.

As the authors wrote, " Results showed ... significant improvements in

reading, spelling, and behavior for active treatment versus placebo

during 3 months of treatment in parallel groups ... [and] ... children

continuing with active treatment maintained or improved their progress. "

Why would an omega-6 fat help kids' brains? While American diets contain

an unhealthful excess of omega-6 fatty acids, some children with

attention disorders may need more of a specific omega-6 called

arachidonic acid (AA) in their brain cells

Evening primrose oil holds therapeutic promise in attention disorders

because it is rich in an omega-6 fatty acid called GLA, which serves as

a precursor to AA.

Researchers hypothesize that a metabolic barrier in all or some children

with attention disorders keeps their bodies from converting enough of

the major omega-6 in people's diets - linoleic acid (LA) from vegetable

oils, meats, nuts, and seeds - into AA.

Omega-6 GLA is an intermediate step in the LA-to-AA conversion process,

so the hope is that GLA-rich supplements can help bypass one metabolic

roadblock to supplying ample AA to kids' brain cell membranes.

Likewise, some researchers hypothesize that a metabolic dysfunction in

all or some children with attention disorders keeps their bodies from

converting enough of the (usually scant) amounts of plant-source

omega-3s in their diets to DHA.

(See " UK Study Finds Fish Oil Benefits Kids with Cognitive Deficits [

http://www.imakenews.com/eletra/go.cfm?z=vitalchoiceseafood%2C299784%2Cb1kJkvww%\

2C857174%2CbdplTfW

" . Note: The supplement used in this trial contained 20%

evening primrose oil, which is high in an omega-6 fatty acid called GLA

.... see our sidebar titled " Why would an omega-6 help kids' brains? " )

Last year, we summarized an Australian clinical trial that produced

mixed results: surveyed parents reported positive changes in their kids,

but teachers did not. (See " Findings Support Omega-3s' Ability to Aid

Kids with Attention Disorders [

http://newsletter.vitalchoice.com/e_article000609244.cfm?x=b7Cr9j7,b1kJpvRw,w

" .)

The evidence on fish oil and ADHD: Tantalizing but inconclusive

Alex Richardson, M.D., of Oxford University is a leading world

researcher in the field of nutrition and diet.

She's a leader of the famous, ongoing Oxford-Durham study, which has

included some of the most rigorous trials - and encouraging results -

regarding the effects of omega-3s on child development. (See her

biography and bibliography at Food and Behaviour Research [

http://www.imakenews.com/eletra/go.cfm?z=vitalchoiceseafood%2C299784%2Cb1kJkvww%\

2C2650906%2CbdplTfW

], the UK charity she co-founded.)

Dr. Richardson has conducted several clinical trials testing omega-3s in

child development and attention disorders, including one in which

supplementation with omega-3s produced clear benefits in 41 children

with ADHD: " ...supplementation with [omega-3s] appears to reduce

ADHD-related symptoms in children with specific learning difficulties. "

(Richardson AJ, Puri BK

2002)

It's worth quoting these key points from Dr. Richardson's clear-eyed

review of the scientific literature (Richardson AJ 2006):

- " Omega-3 fatty acids are dietary essentials, and are critical to brain

development and function. Increasing evidence suggests that a relative

lack of omega-3 may contribute to many psychiatric and

neuro-developmental disorders. "

- " Results from controlled treatment trials are mixed, but the few

studies in this area have involved different populations and treatment

formulations. "

- " Dietary supplementation with fish oils (providing EPA and DHA)

appears to alleviate ADHD-related symptoms in at least some children,

and one study ... also found benefits for academic achievement. "

- " Larger trials are now needed to confirm these findings, and to

establish the specificity and durability of any treatment effects as

well as optimal formulations and dosages. "

- " Omega-3 is not supported by current evidence as a primary treatment

for ADHD or related conditions, but further research in this area is

clearly warranted. "

- " Given their relative safety and general health benefits, omega-3

fatty acids offer a promising complementary approach to standard

treatments. "

The Times article quoted Tufts University pediatric health expert

Elizabeth Busch, M.D., who put her finger on the evidentiary problem in

a recent literature review: " Because of the variety of subjects and

inconsistencies in methodology, this growing literature lacks

cohesiveness and is more tantalizing than persuasive. " (Busch B 2007)

Since 2000, there have been seven published studies in children that

looked at ADHD-related behavioral outcomes following fish oil treatment,

and their deficiencies and inconsistencies make it impossible to draw

clear conclusions:

- Only four of the seven studies involved children formally diagnosed

with ADHD.

- The studies were conducted in five different countries with varied

dietary patterns.

- Few studies controlled for maternal smoking and/or alcohol consumption

- both of which can impair metabolism of omega-3s and omega-6s - during

the children's gestation.

- Few studies recorded whether subjects were breast-/bottle-fed during

infancy. (This oversight is important because, as we reported recently,

maternal omega-3 intake during pregnancy and nursing appears to affect

child development; see " Child Benefits of Fish Affirmed in Large Study [

http://newsletter.vitalchoice.com/e_article001203932.cfm?x=b11,0,w

" .).

- No study considered the children's overall omega-6/omega-3 intake

ratio. (These two classes of fatty acid have very different effects, and

compete for uptake into brain cells ... an excess of dietary omega-6s

can reduce the proportion of omega-3s in brain cells.)

And when the Canadian authors of a July 2005 report - funded by the U.S.

National Institutes of Health - examined the available studies relating

to pediatric ADHD, they could not come to any definitive conclusions

concerning the value of omega-3s as a primary or adjunct treatment for

ADHD (Schachter H et al.

2005)

What's the future of omega-3s in ADHD?

We still know relatively little about the different effects of the two

key omega-3s (EPA and DHA) and the varying effects of different blends

of omega-3s and omega-6s.

These important questions remain unanswered:

- Do the thinking, emotional, and behavior problems seen in ADHD and

related conditions stem from deficiencies in certain children's intake

of omega-3s, or in their ability to metabolize dietary omega-3s?

- Can all or some children diagnosed with ADHD benefit from taking fish

oil, which is rich in omega-3s?

- If some children can benefit from the omega-3s in fish oil, what doses

and ratios of the key fish-derived omega-3s - DHA and EPA - are most

effective?

- Does the ratio of omega-3s to omega-6s in children's overall diets

matter?

- Should some or all children with ADHD take selected omega-6s as well

as omega-3 fish oil?

- If some children can benefit from fish oil, how long would they need

to take fish oil (or a combination of omega-3 and omega-6 fatty acids)

before positive results begin to appear and reach their maximum level?

Sadly, only drug companies have the resources to run the several

large-scale, long-term trials needed to settle these key questions ...

and, if warranted, gain FDA approval of fish oil as a treatment for ADHD

or related disorders.

But because drug companies cannot patent omega-3s, they have little or

no motive to spend the $200 million-plus it would take to gain FDA

approval of fish oil as an ADHD drug.

What's needed is a taxpayer-funded program to test natural products like

omega-3s and vitamin D as treatments for, and/or preventive allies

against, common diseases.

The NIH has long had a program to fund nutrition-disease studies at

universities around the U.S., but it is not designed to answer the

practical questions.

Americans should demand that Congress fund this urgent unmet need.

In the meantime, one thing seems certain: fish oil is safe, and unlikely

to do harm.

So it makes sense for parents of affected children to discuss fish oil

with their pediatrician as an initial or adjunct approach.

SIDEBAR

The Times mention of Mayo's clinical trial misleads The Times article

mentioned both of the above studies, but added that a four-month Mayo

Clinic trial involving 63 children found no decrease in ADHD symptoms

after four months of omega-3 DHA supplementation therapy (345 mg per

day).

However, the Times article failed to note that, as the

researchers wrote, the kids in the Mayo Clinic trial were " ... all

receiving effective maintenance therapy with stimulant

medication. "

In other words, the children had been taking Ritalin-type drugs for some

time, which had already reduced their symptoms substantially (Voigt RG

et al. 2001).

Thus, the Times article leaves the impression that the Mayo Clinic trial

was a meaningful test of the effects of omega-3s in ADHD. In fact, all

the results showed was that omega-3 DHA did not reduce the kids'

symptoms further.

While this is nice to know, it's not terribly surprising or helpful, nor

does it mean that the supplemental DHA given the children did not

improve mental functions that were not measured in the trial.

END

Sources

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Omega-3 fatty acid status in attention-deficit/hyperactivity disorder.

Prostaglandins Leukot Essent Fatty Acids. 2006 Oct-Nov;75(4-5):299-308.

Epub 2006 Sep

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- Burgess JR, Stevens L, Zhang W, Peck L. Long-chain polyunsaturated

fatty acids in children with attention-deficit hyperactivity disorder.

Am J Clin Nutr. 2000 Jan;71(1 Suppl):327S-30S. Review.

- Busch B. Polyunsaturated fatty acid supplementation for ADHD? Fishy,

fascinating, and far from clear. J Dev Behav Pediatr. 2007

Apr;28(2):139-44.

- Frolich J, Dopfner M. [The treatment of

Attention-Deficit/Hyperactivity Disorders with polyunsaturated fatty

acids - an effective treatment alternative?] Z Kinder Jugendpsychiatr

Psychother. 2008 Mar;36(2):109-16. Review. German.

- Germano M, Meleleo D, Montorfano G, Adorni L, Negroni M, Berra B,

Rizzo AM. Plasma, red blood cells phospholipids and clinical evaluation

after long chain omega-3 supplementation in children with attention

deficit hyperactivity disorder (ADHD). Nutr Neurosci. 2007

Feb-Apr;10(1-2):1-9.

- Rabin RC. Feeling Good About Fish Oil. The New York Times. September

15, 2008. Accessed online September 15, 2008 at

http://www.imakenews.com/eletra/go.cfm?z=vitalchoiceseafood%2C299784%2Cb1kJkvww%\

2C2650931%2CbdplTfW

- Richardson AJ, Puri BK. A randomized double-blind, placebo-controlled

study of the effects of supplementation with highly unsaturated fatty

acids on ADHD-related symptoms in children with specific learning

difficulties. Prog Neuropsychopharmacol Biol Psychiatry. 2002

Feb;26(2):233-9.

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attention-deficit/hyperactivity disorder. Prostaglandins Leukot Essent

Fatty Acids. 2000 Jul-Aug;63(1-2):79-87. Review.

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neurodevelopmental disorders. Int Rev Psychiatry. 2006 Apr;18(2):155-72.

Review.

- Schachter HM, Kourad K, Merali Z, Lumb A, Tran K, Miguelez M. Effects

of omega-3 fatty acids on mental health.Evid Rep Technol Assess (Summ).

2005 Jul;(116):1-11. Review.

- Sinn N, Bryan J. Effect of supplementation with polyunsaturated fatty

acids and micronutrients on learning and behavior problems associated

with child ADHD. J Dev Behav Pediatr. 2007 Apr;28(2):82-91.

- Sinn N. Polyunsaturated fatty acid supplementation for ADHD symptoms:

response to commentary. J Dev Behav Pediatr. 2007 Jun;28(3):262-3.

- Voigt RG, Llorente AM, Jensen CL, Fraley JK, Berretta MC, Heird WC. A

randomized, double-blind, placebo-controlled trial of docosahexaenoic

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