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Zhou P, Yu X, Song T, Hou X. Safety and efficacy of antioxidant therapy in children and adolescents with attention deficit hyperactivity disorder: A systematic review and network meta-analysis. PLoS One 2024; 19:e0296926. [PMID: 38547138 PMCID: PMC10977718 DOI: 10.1371/journal.pone.0296926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 12/22/2023] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE To systematically evaluate the safety and efficacy of antioxidant therapy in children and adolescents with attention deficit hyperactivity disorder (ADHD). METHODS Randomized controlled trials and prospective studies on antioxidant therapy in children and adolescents with ADHD were searched in PubMed, Embase, and Cochrane Library from the inception of databases to November 12, 2022. Two investigators independently screened the literature, extracted data, and evaluated the quality of the included studies. Network meta-analysis (PROSPERO registration number CRD 42023382824) was carried out by using R Studio 4.2.1. RESULTS 48 studies involving 12 antioxidant drugs (resveratrol, pycnogenol, omega-3, omega-6, quercetin, phosphatidylserine, almond, vitamin D, zinc, folic acid, ginkgo biloba, Acetyl-L-carnitine) were finally included, with 3,650 patients. Network meta-analysis showed that omega-6 (0.18), vitamin D (0.19), and quercetin (0.24) were the top three safest drugs according to SUCRA. The omega-3 (SUCRA 0.35), pycnogenol (SUCRA 0.36), and vitamin D (SUCRA 0.27) were the most effective in improving attention, hyperactivity, and total score of Conners' parent rating scale (CPRS), respectively. In terms of improving attention, hyperactivity, and total score of Conners' teacher rating scale (CTRS), pycnogenol (SUCRA 0.32), phosphatidylserine+omega-3 (SUCRA 0.26), and zinc (SUCRA 0.34) were the most effective, respectively. In terms of improving attention, hyperactivity and total score of ADHD Rating Scale-Parent, the optimal agents were phosphatidylserine (SUCRA 0.39), resveratrol+MPH (SUCRA 0.24), and phosphatidylserine (SUCRA 0.34), respectively. In terms of improving attention, hyperactivity and total score of ADHD Rating Scale-Teacher, pycnogenol (SUCRA 0.32), vitamin D (SUCRA 0.31) and vitamin D (SUCRA 0.18) were the optimal agents, respectively. The response rate of omega-3+6 was the highest in CGI (SUCRA 0.95) and CPT (SUCRA 0.42). CONCLUSION The rankings of safety and efficacy of the 12 antioxidants vary. Due to the low methodological quality of the included studies, the probability ranking cannot fully explain the clinical efficacy, and the results need to be interpreted with caution. More high-quality studies are still needed to verify our findings.
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Affiliation(s)
- Peike Zhou
- Department of Pediatrics, Affiliated ZhongShan Hospital of Dalian University, Dalian, Liaoning, China
| | - Xiaohui Yu
- Department of Pediatrics, Affiliated ZhongShan Hospital of Dalian University, Dalian, Liaoning, China
| | - Tao Song
- Department of Pediatrics, Affiliated ZhongShan Hospital of Dalian University, Dalian, Liaoning, China
| | - Xiaoli Hou
- Department of Pediatrics, Affiliated ZhongShan Hospital of Dalian University, Dalian, Liaoning, China
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Gillies D, Leach MJ, Perez Algorta G. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev 2023; 4:CD007986. [PMID: 37058600 PMCID: PMC10103546 DOI: 10.1002/14651858.cd007986.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age-inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long-term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega-3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents. OBJECTIVES To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents. SEARCH METHODS We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow-up; and cost. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross-over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega-3 PUFA, six used a combined omega-3/omega-6 supplement, and two used an omega-6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co-intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega-3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega-3 PUFA plus atomoxetine to atomoxetine; omega-3 PUFA plus physical training to physical training; and an omega-3 or omega-6 supplement plus methylphenidate to methylphenidate; and two trials compared omega-3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low-certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high-certainty evidence that PUFA had no effect on parent-rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) -0.08, 95% CI -0.24 to 0.07; 16 studies, 1166 participants). There was also high-certainty evidence that parent-rated inattention (medium-term: SMD -0.01, 95% CI -0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium-term: SMD 0.09, 95% CI -0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate-certainty evidence that medium-term loss to follow-up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants). AUTHORS' CONCLUSIONS Although we found low-certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high-certainty evidence that PUFA had no effect on total parent-rated ADHD symptoms. There was also high-certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate-certainty evidence that follow-up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow-up times.
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Affiliation(s)
- Donna Gillies
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Matthew J Leach
- School of Nursing & Midwifery, University of South Australia, Adelaide, Australia
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Borasio F, De Cosmi V, D’Oria V, Scaglioni S, Syren MLE, Turolo S, Agostoni C, Coniglio M, Molteni M, Antonietti A, Lorusso ML. Associations between Dietary Intake, Blood Levels of Omega-3 and Omega-6 Fatty Acids and Reading Abilities in Children. Biomolecules 2023; 13:biom13020368. [PMID: 36830737 PMCID: PMC9952928 DOI: 10.3390/biom13020368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Lower levels of omega-3 polyunsaturated fatty acids (PUFAs) have been described in individuals with reading difficulties, but the degree and the nature of such deficiencies as well as the role of nutrition are a matter of debate. The aim of the present study was to investigate the associations between PUFA blood levels, nutritional status, and reading/writing/phonological awareness performances in 42 school-age children with varying levels of reading ability. Significant correlations were found between PUFA levels (specific omega-6/omega-3 ratios), the ratio of omega-6-derived calories to the total amount of calories and reading scores. Mediation analysis showed a mediating effect of fatty acids on the association between reading speed scores and nutritional status. Moderation analysis, moreover, showed that the associations of omega-6/omega-3 ratios in the blood and Kcal omega-6/Kcal total in dietary intake were moderated by reading speed performances. Results of the mediation and moderation models confirm that the associations of dietary intake with PUFA levels in the blood vary depending on learning abilities. Reading skills appear to be sensitive to the effects of a complex set of favorable conditions related to the presence of higher omega-3 blood levels. These conditions may reflect the action of dietary as well as genetic and epigenetic mechanisms.
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Affiliation(s)
- Francesca Borasio
- Scientific Institute IRCSS E. Medea, Unit of Child Psychopathology, 23842 Bosisio Parini, Italy
- Department of Psychology, Catholic University of the Sacred Heart, 20123 Milan, Italy
| | - Valentina De Cosmi
- Department of Clinical and Community Sciences, University of Milan, 20122 Milan, Italy
| | - Veronica D’Oria
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, 20122 Milan, Italy
| | - Silvia Scaglioni
- Fondazione De Marchi, Department of Pediatrics, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | - Stefano Turolo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Nephrology Dialysis and Pediatric Transplantation, 20122 Milan, Italy
| | - Carlo Agostoni
- Department of Clinical and Community Sciences, University of Milan, 20122 Milan, Italy
- SC Pediatria-Immunoreumatologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marilena Coniglio
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Child and Adolescent Neuropsychiatry, 20122 Milan, Italy
| | - Massimo Molteni
- Scientific Institute IRCSS E. Medea, Unit of Child Psychopathology, 23842 Bosisio Parini, Italy
| | - Alessandro Antonietti
- Department of Psychology, Catholic University of the Sacred Heart, 20123 Milan, Italy
| | - Maria Luisa Lorusso
- Scientific Institute IRCSS E. Medea, Unit of Child Psychopathology, 23842 Bosisio Parini, Italy
- Correspondence:
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Omega-3/6 supplementation for mild to moderate inattentive ADHD: a randomised, double-blind, placebo-controlled efficacy study in Italian children. Eur Arch Psychiatry Clin Neurosci 2022; 272:1453-1467. [PMID: 35672606 DOI: 10.1007/s00406-022-01428-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
Recently there has been a growing interest in non-pharmacological treatments for ADHD. We evaluated the efficacy of a specific Omega-3/6 dietary supplement (two capsules containing 279 mg eicosapentaenoic acid [EPA], 87 mg Docosahexaenoic Acid [DHA], 30 mg gamma linolenic acid [GLA] each) in ameliorating inattentive symptoms in inattentive-ADHD children (6-12 years) with a baseline ADHD-RS-Inattention score ≥ 12. Secondary objectives included changes in global functioning, severity of illness, depression, and anxiety symptoms, learning disorders and in the fatty acids blood levels. The study was a randomised, double-blind, placebo-controlled efficacy and safety trial with a 6-month double-blind evaluation of Omega-3/6 vs placebo (Phase-I) and a further 6-month-open-label treatment with Omega-3/6 on all patients (Phase-II). In total 160 subjects were enrolled. No superiority of Omega-3/6 supplement to placebo was observed on the primary outcome (ADHD-RS-inattention score) after the first 6-months, with 46.3% of responders in the Omega-3/6 group and 45.6% in the placebo group; a slight (not statistically significant) reduction in Omega-6/3 ratio blood levels was measured in the active treatment group. Twelve months after enrolment, percentages of responders were similar between groups. A mild statistical, although not clinically significant, improvement was observed on the ADHD-RS-total score in the Omega-3/6 group but not on the ADHD-RS-Inattention score; a slight (not-statistically significant) reduction in Omega-6/3 ratio was observed in the group taking active treatment only during Phase II. In conclusion, no clinical beneficial effects of Omega-3/6 were detected on inattentive symptoms, suggesting a limited role of Omega-3/6 dietary products in children with mild ADHD-I.Trial registration: At the time of the Ethical submission, according to the clinical trial Italian law, registration was not mandatory for food additive as Omega 3/6 were then classified. The trial was approved by the Ethical Committee of the Cagliari University Hospital (resolution n. 662; September 22nd, 2011).
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AKIN S, GÜLTEKİN F, GÜLER EM. Dikkat Eksikliği ve Hiperaktivite Bozukluğunda Yağ Asitlerinin Rolü. ACTA MEDICA ALANYA 2022. [DOI: 10.30565/medalanya.1059552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Attention deficit hyperactivity disorder (ADHD) is a childhood-onset disorder that affects 5% to 12% of children worldwide. Etiological factors, including nutrition, are involved in this disease, which is characterized by inattention, impulsivity, and hyperactivity symptoms. Fats, which form an important part of the daily diet, can have effects on ADHD and its symptoms. In the literature, it is stated that omega-3 fatty acids are low in children with ADHD, and supplementation studies may be effective in improving symptoms. In addition, high omega-6/omega-3 fatty acids ratio in the diet and diets rich in saturated and trans fatty acids are associated with ADHD. In this review, the relationship between ADHD and dietary fatty acids will be evaluated.
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Affiliation(s)
- Sümeyye AKIN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, HAMİDİYE SAĞLIK BİLİMLERİ ENSTİTÜSÜ, TIBBİ BİYOKİMYA (DR)
| | - Fatih GÜLTEKİN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, HAMİDİYE TIP FAKÜLTESİ, TEMEL TIP BİLİMLERİ BÖLÜMÜ, TIBBİ BİYOKİMYA ANABİLİM DALI
| | - Eray Metin GÜLER
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, HAMİDİYE TIP FAKÜLTESİ, TEMEL TIP BİLİMLERİ BÖLÜMÜ, TIBBİ BİYOKİMYA ANABİLİM DALI
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Liu Y, Ren X, Fan C, Wu W, Zhang W, Wang Y. Health Benefits, Food Applications, and Sustainability of Microalgae-Derived N-3 PUFA. Foods 2022; 11:1883. [PMID: 35804698 PMCID: PMC9265382 DOI: 10.3390/foods11131883] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/03/2022] [Accepted: 06/15/2022] [Indexed: 01/27/2023] Open
Abstract
Today's consumers are increasingly aware of the beneficial effects of n-3 PUFA in preventing, delaying, and intervening various diseases, such as coronary artery disease, hypertension, diabetes, inflammatory and autoimmune disorders, neurodegenerative diseases, depression, and many other ailments. The role of n-3 PUFA on aging and cognitive function is also one of the hot topics in basic research, product development, and clinical applications. For decades, n-3 PUFA, especially EPA and DHA, have been supplied by fish oil and seafood. With the continuous increase of global population, awareness about the health benefits of n-3 PUFA, and socioeconomic improvement worldwide, the supply chain is facing increasing challenges of insufficient production. In this regard, microalgae have been well considered as promising sources of n-3 PUFA oil to mitigate the supply shortages. The use of microalgae to produce n-3 PUFA-rich oils has been explored for over two decades and some species have already been used commercially to produce n-3 PUFA, in particular EPA- and/or DHA-rich oils. In addition to n-3 PUFA, microalgae biomass contains many other high value biomolecules, which can be used in food, dietary supplement, pharmaceutical ingredient, and feedstock. The present review covers the health benefits of n-3 PUFA, EPA, and DHA, with particular attention given to the various approaches attempted in the nutritional interventions using EPA and DHA alone or combined with other nutrients and bioactive compounds towards improved health conditions in people with mild cognitive impairment and Alzheimer's disease. It also covers the applications of microalgae n-3 PUFA in food and dietary supplement sectors and the economic and environmental sustainability of using microalgae as a platform for n-3 PUFA-rich oil production.
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Affiliation(s)
- Yanjun Liu
- INNOBIO Corporation Limited, No. 49, DDA, Dalian 116600, China; (Y.L.); (C.F.); (W.W.)
| | - Xiang Ren
- INNOBIO Corporation Limited, No. 49, DDA, Dalian 116600, China; (Y.L.); (C.F.); (W.W.)
| | - Chao Fan
- INNOBIO Corporation Limited, No. 49, DDA, Dalian 116600, China; (Y.L.); (C.F.); (W.W.)
| | - Wenzhong Wu
- INNOBIO Corporation Limited, No. 49, DDA, Dalian 116600, China; (Y.L.); (C.F.); (W.W.)
| | - Wei Zhang
- DeOxiTech Consulting, 30 Cloverfield Court, Dartmouth, NS B2W 0B3, Canada;
| | - Yanwen Wang
- Aquatic and Crop Resource Development Research Centre, National Research Council of Canada, 550 University Avenue, Charlottetown, PE C1A 4P3, Canada
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Morandini HAE, Rao P, Hood SD, Griffiths K, Silk TJ, Zepf FD. Effects of dietary omega-3 intake on vigilant attention and resting-state functional connectivity in neurotypical children and adolescents. Nutr Neurosci 2021; 25:2269-2278. [PMID: 34369315 DOI: 10.1080/1028415x.2021.1955434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vigilant Attention (VA) is a critical cognitive function allowing to maintain our attention, particularly in redundant or intellectually unchallenging situations. Evidence has shown that, as the brain develops, VA abilities rapidly improve throughout childhood and adolescence. Dietary omega-3 polyunsaturated fats (PUFA), playing a critical role for proper brain development and maturation of cortical regions, may contribute to variations in VA abilities. OBJECTIVE The present study investigated the effect of dietary omega-3 PUFA intake (docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)) on resting-state functional connectivity (rsFC) of a meta-analytically defined VA network in 24 neurotypical children and adolescents (7.3-17.2 years) from the Healthy Brain Network databank. METHODS Functional MRI and phenotypical information were collected from the Healthy Brain Network databank. Intake of omega-3 DHA and EPA was assessed using a food frequency questionnaire and was adjusted for total calorie intake. Out of scanner VA-related performance was assessed using the VA condition of the Adaptive Cognitive Evaluation tool. RESULTS Overall, reported intake of omega-3 PUFA was not significantly associated with VA-related performance. Furthermore, energy-adjusted omega-3 intake was not significantly correlated with rsFC within the VA network. A complementary whole-brain analysis revealed that energy-adjusted omega-3 intake was correlated with decreased rsFC between parieto-occipital brain regions. CONCLUSION The present study was not able to detect a relationship between dietary omega-3 and rsFC or VA performance.
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Affiliation(s)
- Hugo A E Morandini
- Centre & Discipline of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.,Division of Psychiatry, UWA Medical School, Faculty of Health & Medical Sciences, The University of Western Australia, Perth, Australia
| | - Pradeep Rao
- Centre & Discipline of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.,Telethon Kids Institute, Perth, Australia.,Child and Adolescent Mental Health Service, Child and Adolescent Health Service, Perth, Australia
| | - Sean D Hood
- Division of Psychiatry, UWA Medical School, Faculty of Health & Medical Sciences, The University of Western Australia, Perth, Australia
| | - Kristi Griffiths
- The Brain Dynamics Centre, Westmead Institute for Medical Research, The University of Sydney, Westmead, Australia
| | - Timothy J Silk
- School of Psychology, Deakin University, Geelong, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Florian D Zepf
- Centre & Discipline of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.,Telethon Kids Institute, Perth, Australia.,Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University, Jena, Germany
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Basak S, Mallick R, Banerjee A, Pathak S, Duttaroy AK. Maternal Supply of Both Arachidonic and Docosahexaenoic Acids Is Required for Optimal Neurodevelopment. Nutrients 2021; 13:2061. [PMID: 34208549 PMCID: PMC8234848 DOI: 10.3390/nu13062061] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 12/22/2022] Open
Abstract
During the last trimester of gestation and for the first 18 months after birth, both docosahexaenoic acid,22:6n-3 (DHA) and arachidonic acid,20:4n-6 (ARA) are preferentially deposited within the cerebral cortex at a rapid rate. Although the structural and functional roles of DHA in brain development are well investigated, similar roles of ARA are not well documented. The mode of action of these two fatty acids and their derivatives at different structural-functional roles and their levels in the gene expression and signaling pathways of the brain have been continuously emanating. In addition to DHA, the importance of ARA has been much discussed in recent years for fetal and postnatal brain development and the maternal supply of ARA and DHA. These fatty acids are also involved in various brain developmental processes; however, their mechanistic cross talks are not clearly known yet. This review describes the importance of ARA, in addition to DHA, in supporting the optimal brain development and growth and functional roles in the brain.
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Affiliation(s)
- Sanjay Basak
- Molecular Biology Division, ICMR-National Institute of Nutrition, Indian Council of Medical Research, Hyderabad 500 007, India;
| | - Rahul Mallick
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70210 Kuopio, Finland;
| | - Antara Banerjee
- Department of Medical Biotechnology, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education (CARE), Chettinad Hospital and Research Institute (CHRI), Kelambakkam, Chennai 603 103, India; (A.B.); (S.P.)
| | - Surajit Pathak
- Department of Medical Biotechnology, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education (CARE), Chettinad Hospital and Research Institute (CHRI), Kelambakkam, Chennai 603 103, India; (A.B.); (S.P.)
| | - Asim K. Duttaroy
- Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, 0317 Oslo, Norway
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Händel MN, Rohde JF, Rimestad ML, Bandak E, Birkefoss K, Tendal B, Lemcke S, Callesen HE. Efficacy and Safety of Polyunsaturated Fatty Acids Supplementation in the Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents: A Systematic Review and Meta-Analysis of Clinical Trials. Nutrients 2021; 13:1226. [PMID: 33917727 PMCID: PMC8068201 DOI: 10.3390/nu13041226] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022] Open
Abstract
Based on epidemiological and animal studies, the rationale for using polyunsaturated fatty acids (PUFAs) as a treatment for Attention Deficit Hyperactivity Disorder (ADHD) seems promising. Here, the objective was to systematically identify and critically assess the evidence from clinical trials. The primary outcome was ADHD core symptoms. The secondary outcomes were behavioral difficulties, quality of life, and side effects. We performed a systematic search in Medline, Embase, Cinahl, PsycInfo, and the Cochrane Library up to June 2020. The overall certainty of evidence was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). We identified 31 relevant randomized controlled trials including 1755 patients. The results showed no effect on ADHD core symptoms rated by parents (k = 23; SMD: -0.17; 95% CI: -0.32, -0.02) or teachers (k = 10; SMD: -0.06; 95% CI: -0.31, 0.19). There was no effect on behavioral difficulties, rated by parents (k = 7; SMD: -0.02; 95% CI: -0.17, 0.14) or teachers (k = 5; SMD: -0.04; 95% CI: -0.35, 0.26). There was no effect on quality of life (SMD: 0.01; 95% CI: -0.29, 0.31). PUFA did not increase the occurrence of side effects. For now, there seems to be no benefit of PUFA in ADHD treatment; however, the certainty of evidence is questionable, and thus no conclusive guidance can be made. The protocol is registered in PROSPERO ID: CRD42020158453.
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Affiliation(s)
- Mina Nicole Händel
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, The Capital Region, 2000 Frederiksberg, Denmark; (J.F.R.); (E.B.)
- The Danish Health Authority, 2300 Copenhagen, Denmark; (K.B.); (B.T.); (H.E.C.)
| | - Jeanett Friis Rohde
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, The Capital Region, 2000 Frederiksberg, Denmark; (J.F.R.); (E.B.)
- The Danish Health Authority, 2300 Copenhagen, Denmark; (K.B.); (B.T.); (H.E.C.)
| | | | - Elisabeth Bandak
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, The Capital Region, 2000 Frederiksberg, Denmark; (J.F.R.); (E.B.)
- The Danish Health Authority, 2300 Copenhagen, Denmark; (K.B.); (B.T.); (H.E.C.)
| | - Kirsten Birkefoss
- The Danish Health Authority, 2300 Copenhagen, Denmark; (K.B.); (B.T.); (H.E.C.)
| | - Britta Tendal
- The Danish Health Authority, 2300 Copenhagen, Denmark; (K.B.); (B.T.); (H.E.C.)
| | - Sanne Lemcke
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, 8200 Aarhus N, Denmark;
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Martinat M, Rossitto M, Di Miceli M, Layé S. Perinatal Dietary Polyunsaturated Fatty Acids in Brain Development, Role in Neurodevelopmental Disorders. Nutrients 2021; 13:1185. [PMID: 33918517 PMCID: PMC8065891 DOI: 10.3390/nu13041185] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 12/26/2022] Open
Abstract
n-3 and n-6 polyunsaturated fatty acids (PUFAs) are essential fatty acids that are provided by dietary intake. Growing evidence suggests that n-3 and n-6 PUFAs are paramount for brain functions. They constitute crucial elements of cellular membranes, especially in the brain. They are the precursors of several metabolites with different effects on inflammation and neuron outgrowth. Overall, long-chain PUFAs accumulate in the offspring brain during the embryonic and post-natal periods. In this review, we discuss how they accumulate in the developing brain, considering the maternal dietary supply, the polymorphisms of genes involved in their metabolism, and the differences linked to gender. We also report the mechanisms linking their bioavailability in the developing brain, their transfer from the mother to the embryo through the placenta, and their role in brain development. In addition, data on the potential role of altered bioavailability of long-chain n-3 PUFAs in the etiologies of neurodevelopmental diseases, such as autism, attention deficit and hyperactivity disorder, and schizophrenia, are reviewed.
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11
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Jia K, Feng Y, Brenna JT, Luo ZC, Zhao J, Li H, Li P, Zhang Q, Zhao Q, Dai Q, Zhong Y, Lambers T, Zhang H, Zhou H, Gao Y. Breast milk EPA associated with infant distractibility when EPA level is low. Nutrition 2021; 86:111143. [PMID: 33601118 DOI: 10.1016/j.nut.2021.111143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/10/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Dietary ω-3 polyunsaturated fatty acids (ω-3 PUFAs) may affect infants' executive function (EF), although it remains unclear whether this may be the effect of total ω-3 PUFAs or any specific ω-3 PUFA. We assessed the associations between ω-3 PUFAs in breast milk and EF in infants at 8 mo of age. METHODS Milk samples from the mothers of 120 breast-fed infants were collected at 42 d and 8 mo postpartum in Beijing, China. Infant's EF was evaluated by planning tasks and A-not-B tasks, including working memory, distractibility, and inhibition of prepotent response at age 8 mo. RESULTS Eicosapentaenoic acid (EPA) concentrations in breast milk were significantly higher at 42 d than 8 mo postpartum. Breast milk EPA levels at both 42 d (P = 0.037) and 8 mo (P = 0.005) postpartum were negatively associated with infant distractibility when EPA levels were low (< 0.05%). No significant association was observed for other ω-3 PUFAs with infant EF scores. CONCLUSIONS Our results suggest a beneficial effect of higher EPA in breast milk (improving infant's attention) when its levels are below a certain threshold.
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Affiliation(s)
- Keyu Jia
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Yao Feng
- National Institute of Health Data Science at Peking University, Beijing, China; Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - J Thomas Brenna
- Departments of Pediatrics, Chemistry, and Human Nutrition, Dell Pediatric Research Institute, University of Texas at Austin, Austin, Texas, USA
| | - Zhong-Cheng Luo
- Lunenfeld-Tanenbaum Research Institute, Obstetrics and Gynecology, Mount Sinai Hospital, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jing Zhao
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Hong Li
- Core Facility of Molecular Biology, Institute of Biochemistry and Cell Biology, Chinese Academy of Sciences, Shanghai, China
| | - Peiqin Li
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Qiuyi Zhang
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Qianyu Zhao
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Qi Dai
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Yan Zhong
- Mead Johnson Pediatric Nutrition Institute, Shanghai, China/Nijmegen, the Netherlands
| | - Tim Lambers
- Mead Johnson Pediatric Nutrition Institute, Shanghai, China/Nijmegen, the Netherlands
| | - Hong Zhang
- Department of Statistics and Finance, School of Management, University of Science and Technology of China, Hefei, China
| | - Hong Zhou
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China.
| | - Ying Gao
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China.
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12
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Efficacy of Polyunsaturated Fatty Acids (PUFAs) on Impulsive Behaviours and Aggressiveness in Psychiatric Disorders. Int J Mol Sci 2021; 22:ijms22020620. [PMID: 33435512 PMCID: PMC7826871 DOI: 10.3390/ijms22020620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 02/08/2023] Open
Abstract
It is the focus of increasing interest to investigate the effects of long-chain n-3 and long-chain n-6 polyunsaturated fatty acids (LC n-3 PUFAs; LC n-6 PUFAs) on psychiatric symptoms in a transdiagnostic perspective. There is some evidence that low levels of LC n-3 PUFAs and a higher ratio of LC n-6 to LC n-3 PUFAs in plasma and blood cells are associated with aggressive and impulsive behaviours. Therefore, implementation of LC n-3 PUFAs may produce positive effects on hostility, aggression, and impulsivity in both psychiatric and non-psychiatric samples across different stages of life. A possible mechanism of action of LC n-3 PUFAs in conditions characterized by a high level of impulsivity and aggression is due to the effect of these compounds on the serotonin system and membrane stability. Studies that evaluated the effects of LC n-3 PUFAs on impulsivity and aggressiveness indicated that addition of rather low doses of these agents to antipsychotic treatment might reduce agitation and violent behaviours in psychosis, attention deficit hyperactivity disorder, personality disorders, and impulsive control and conduct disorders. The present review is aimed at examining and discussing available data from recent trials on this topic.
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13
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Metabolic Flexibility Assists Reprograming of Central and Peripheral Innate Immunity During Neurodevelopment. Mol Neurobiol 2020; 58:703-718. [PMID: 33006752 DOI: 10.1007/s12035-020-02154-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/28/2020] [Indexed: 01/03/2023]
Abstract
Central innate immunity assists time-dependent neurodevelopment by recruiting and interacting with peripheral immune cells. Microglia are the major player of central innate immunity integrating peripheral signals arising from the circumventricular regions lacking the blood-brain barrier (BBB), via neural afferent pathways such as the vagal nerve and also by choroid plexus into the brain ventricles. Defective and/or unrestrained activation of central and peripheral immunity during embryonic development might set an aberrant connectome establishment and brain function, leading to major psychiatric disorders in postnatal stages. Molecular candidates leading to central and peripheral innate immune overactivation identified metabolic substrates and lipid species as major contributors of immunological priming, supporting the role of a metabolic flexibility node during trained immunity. Mechanistically, trained immunity is established by an epigenetic program including DNA methylation and histone acetylation, as the major molecular epigenetic signatures to set immune phenotypes. By definition, immunological training sets reprogramming of innate immune cells, enhancing or repressing immune responses towards a second challenge which potentially might contribute to neurodevelopment disorders. Notably, the innate immune training might be set during pregnancy by maternal immune activation stimuli. In this review, we integrate the most valuable scientific evidence supporting the role of metabolic cues assisting metabolic flexibility, leading to innate immune training during development and its effects on aberrant neurological phenotypes in the offspring. We also add reports supporting the role of methylation and histone acetylation signatures as a major epigenetic mechanism regulating immune training.
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14
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Yde Ohki CM, Grossmann L, Alber E, Dwivedi T, Berger G, Werling AM, Walitza S, Grünblatt E. The stress-Wnt-signaling axis: a hypothesis for attention-deficit hyperactivity disorder and therapy approaches. Transl Psychiatry 2020; 10:315. [PMID: 32948744 PMCID: PMC7501308 DOI: 10.1038/s41398-020-00999-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/27/2022] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is one of the most common psychiatric neurodevelopmental disorders in children and adolescents. Although ADHD has been studied for nearly a century, the cause and pathophysiology of ADHD is yet largely unknown. However, findings from previous studies have resulted in the formation of a new hypothesis: Apart from the well-known multifactorial etiology of ADHD, recent evidence suggests that the interaction between genetic and environmental factors and especially Wnt- and mTOR-signaling pathways might have an important role in the pathophysiology of ADHD. The Wnt-signaling pathway is known to orchestrate cellular proliferation, polarity, and differentiation, and the mTOR pathway is involved in several significant processes of neurodevelopment and synaptic plasticity. As a result, dysregulations of these pathways in a time-dependent manner could lead to neurodevelopmental delays, resulting in ADHD phenotype. This review presents further evidence supporting our hypothesis by combining results from studies on ADHD and Wnt- or mTOR-signaling and the influence of genetics, methylphenidate treatment, Omega-3 supplementation, and stress.
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Affiliation(s)
- Cristine Marie Yde Ohki
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
| | - Leoni Grossmann
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
| | - Emma Alber
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
| | - Tanushree Dwivedi
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
| | - Gregor Berger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
| | - Anna Maria Werling
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland
- Neuroscience Center Zurich, University of Zurich and the ETH Zurich, Zürich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zürich, Switzerland
| | - Edna Grünblatt
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zürich, Switzerland.
- Neuroscience Center Zurich, University of Zurich and the ETH Zurich, Zürich, Switzerland.
- Zurich Center for Integrative Human Physiology, University of Zurich, Zürich, Switzerland.
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15
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Rosi E, Grazioli S, Villa FM, Mauri M, Gazzola E, Pozzi M, Molteni M, Nobile M. Use of Non-Pharmacological Supplementations in Children and Adolescents with Attention Deficit/Hyperactivity Disorder: A Critical Review. Nutrients 2020; 12:nu12061573. [PMID: 32481502 PMCID: PMC7352506 DOI: 10.3390/nu12061573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/31/2022] Open
Abstract
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children and adolescents, with environmental and biological causal influences. Pharmacological medication is the first choice in ADHD treatment; recently, many studies have concentrated on dietary supplementation approaches to address nutritional deficiencies, to which part of non-responses to medications have been imputed. This review aims to evaluate the efficacy of non-pharmacological supplementations in children or adolescents with ADHD. We reviewed 42 randomized controlled trials comprised of the following supplementation categories: polyunsaturated fatty acids (PUFAs), peptides and amino acids derivatives, single micronutrients, micronutrients mix, plant extracts and herbal supplementations, and probiotics. The reviewed studies applied heterogeneous methodologies, thus making it arduous to depict a systematic overview. No clear effect on single cognitive, affective, or behavioral domain was found for any supplementation category. Studies on PUFAs and micronutrients found symptomatology improvements. Peptides and amino acids derivatives, plant extracts, herbal supplementation, and probiotics represent innovative research fields and preliminary results may be promising. In conclusion, such findings, if confirmed through future research, should represent evidence for the efficacy of dietary supplementation as a support to standard pharmacological and psychological therapies in children and adolescents with ADHD.
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Affiliation(s)
- Eleonora Rosi
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy; (E.R.); (F.M.V.); (M.M.); (M.M.); (M.N.)
| | - Silvia Grazioli
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy; (E.R.); (F.M.V.); (M.M.); (M.M.); (M.N.)
- Correspondence:
| | - Filippo Maria Villa
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy; (E.R.); (F.M.V.); (M.M.); (M.M.); (M.N.)
| | - Maddalena Mauri
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy; (E.R.); (F.M.V.); (M.M.); (M.M.); (M.N.)
- PhD Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Erica Gazzola
- Department of Psychology, University of Milano Bicocca, 20126 Milan, Italy;
| | - Marco Pozzi
- Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy;
| | - Massimo Molteni
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy; (E.R.); (F.M.V.); (M.M.); (M.M.); (M.N.)
| | - Maria Nobile
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy; (E.R.); (F.M.V.); (M.M.); (M.M.); (M.N.)
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16
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Bozzatello P, Rocca P, Mantelli E, Bellino S. Polyunsaturated Fatty Acids: What is Their Role in Treatment of Psychiatric Disorders? Int J Mol Sci 2019; 20:E5257. [PMID: 31652770 PMCID: PMC6862261 DOI: 10.3390/ijms20215257] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 12/12/2022] Open
Abstract
In the central nervous system omega-3 fatty acids modulate cell signaling and affect dopaminergic and serotonergic pathways. On this basis, a new application for omega-3 fatty acids has been proposed, concerning the treatment of several psychiatric disorders. The present article is an update of a previous systematic review and is aimed to provide a complete report of data published in the period between 1980 and 2019 on efficacy and tolerability of omega-3 fatty acids in psychiatric disorders. In July 2019, an electronic search on PUBMED, Medline and PsychINFO of all RCTs, systematic reviews and meta-analyses on omega-3 fatty acids and psychiatric disorders without any filter or MESH restriction was performed. After eligibility processes, the final number of records included in this review was 126. One hundred and two of these studies were RCTs, while 24 were reviews and meta-analyses. The role of omega-3 fatty acids was studied in schizophrenia, major depression, bipolar disorder, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, eating disorders, substance use disorder and borderline personality disorder. The main evidence of the efficacy of omega-3 fatty acids has been obtained in treating depressive symptoms in patients with major depression and, to a lesser degree, bipolar depression. Some efficacy was also found in early phases of schizophrenia in addition to antipsychotic treatment, but not in the chronic phases of psychosis. Small beneficial effects of omega-3 fatty acids were observed in ADHD and positive results were reported in a few trials on core symptoms of borderline personality disorder. For other psychiatric disorders results are inconsistent.
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Affiliation(s)
- Paola Bozzatello
- Department of Neuroscience, University of Turin, 10125 Turin, Italy.
| | - Paola Rocca
- Department of Neuroscience, University of Turin, 10125 Turin, Italy.
| | - Emanuela Mantelli
- Department of Neuroscience, University of Turin, 10125 Turin, Italy.
| | - Silvio Bellino
- Department of Neuroscience, University of Turin, 10125 Turin, Italy.
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17
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Cagigal C, Silva T, Jesus M, Silva C. Does Diet Affect the Symptoms of ADHD? Curr Pharm Biotechnol 2019; 20:130-136. [PMID: 30255748 DOI: 10.2174/1389201019666180925140733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/19/2018] [Accepted: 07/30/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric diagnosis in childhood and adolescence, with an estimated worldwide-pooled prevalence of 5,29%. The type of treatment depends on several factors. Psychopharmacological treatment entails undesirable side effects, with unclear long-term benefits, which has led the scientific community to investigate other therapeutic approaches, such as dietary interventions. METHOD The authors conducted a classical review on the current treatment recommended in individuals with ADHD diagnosis, their dietary patterns, as well as dietary factors possibly implicated in the etiology and treatment of this disorder. An extensive bibliographic research was carried out in the databases PubMed, The Cochrane Library and the National Guideline Clearinghouse. DISCUSSION The most common dietary interventions in the case of ADHD are food supplementation diets (e.g. PUFAs, vitamins) and elimination diets. Supplementation with omega-3 PUFAs lacks further studies that can validate them as an effective therapeutic approach in this disorder. Also, regarding vitamin supplementation, studies are not consistent as to their role in the etiology of ADHD. Elimination diets are unclear as to the benefits provided in individuals with ADHD. Children with ADHD are less likely to engage in healthy lifestyle behaviors than non-ADHD youth. CONCLUSION There is no clear evidence that supports dietary interventions for the treatment of ADHD. The effects of unhealthy diet patterns in ADHD individuals are not yet fully understood and, like the general population, children with ADHD may benefit from a healthy lifestyle.
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Affiliation(s)
- César Cagigal
- Department of Psychiatry, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Tánia Silva
- Department of Psychiatry, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Mariana Jesus
- Department of Psychiatry, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Carla Silva
- Department of Psychiatry, Coimbra Hospital and University Centre, Coimbra, Portugal
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18
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The effectiveness of omega-3 supplementation in reducing ADHD associated symptoms in children as measured by the Conners' rating scales: A systematic review of randomized controlled trials. J Psychiatr Res 2019; 110:64-73. [PMID: 30594823 DOI: 10.1016/j.jpsychires.2018.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/04/2018] [Accepted: 12/05/2018] [Indexed: 11/24/2022]
Abstract
Omega-3 supplements are considered to have anti-inflammatory effects which may be beneficial as inflammation has been linked to ADHD. The aim of this review is to examine the effectiveness of omega-3 supplementation at reducing ADHD symptoms in children and adolescents. Medline, Cinahl+, PsycINFO, Cochrane and Embase were searched for trials investigating the effects of omega-3 supplementation in children and adolescents with ADHD. The primary outcome measure was a mean difference in Conners' rating scale (CRS) between the intervention and placebo group. Search terms used include ADHD, omega-3, fish oils, eicosapentaenoic acid, docosahexaenoic acids, alpha-linolenic acid and Conners' rating scale. Randomized controlled trials examining the efficacy of omega-3 supplementation in children and adolescents as measured by CRS were included. Studies using a combination of polyunsaturated fatty acids or any other rating scale were excluded. Seven trials were included in this review, totalling 926 participants. We found no evidence of publication bias or heterogeneity between trials. Overall, there was a slightly greater reduction in CRS score in favour of the experiment group. One study found a greater reduction in score in favour of the placebo group. Neither findings were statistically significant. There is little supportive evidence to validate the claim of omega-3 supplementation to reduce the degree of ADHD symptoms experienced by children and adolescents. Both experiment and control groups saw similar reductions in Conners rating scale score.
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19
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Goode AP, Coeytaux RR, Maslow GR, Davis N, Hill S, Namdari B, LaPointe NMA, Befus D, Lallinger KR, Bowen SE, Kosinski A, McBroom AJ, Sanders GD, Kemper AR. Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review. Pediatrics 2018; 141:peds.2018-0094. [PMID: 29848556 DOI: 10.1542/peds.2018-0094] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD) encompass a range of care approaches from structured behavioral interventions to complementary medicines. OBJECTIVES To assess the comparative effectiveness of nonpharmacologic treatments for ADHD among individuals 17 years of age and younger. DATA SOURCES PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2009 through November 7, 2016. STUDY SELECTION We included studies that compared any ADHD nonpharmacologic treatment strategy with placebo, pharmacologic, or another nonpharmacologic treatment. DATA EXTRACTION Study design, patient characteristics, intervention approaches, follow-up times, and outcomes were abstracted. For comparisons with at least 3 similar studies, random-effects meta-analysis was used to generate pooled estimates. RESULTS We identified 54 studies of nonpharmacologic treatments, including neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled results for omega fatty acids found no significant effects for parent rating of ADHD total symptoms (n = 411; standardized mean difference -0.32; 95% confidence interval -0.80 to 0.15; I2 = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized mean difference -0.08; 95% confidence interval -0.47 to 0.32; I2 = 0.0%; P = .56). LIMITATIONS Studies often did not reflect the primary care setting and had short follow-up periods, small sample sizes, variations in outcomes, and inconsistent reporting of comparative statistical analyses. CONCLUSIONS Despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.
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Affiliation(s)
- Adam P Goode
- Duke Orthopaedic Surgery.,Duke Clinical Research Institute, and
| | - Remy R Coeytaux
- Department of Family and Community Medicine and.,Center of Integrative Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Gary R Maslow
- Departments of Psychiatry and Behavioral Sciences.,Pediatrics, and
| | - Naomi Davis
- Departments of Psychiatry and Behavioral Sciences
| | - Sherika Hill
- Departments of Psychiatry and Behavioral Sciences
| | | | | | - Deanna Befus
- Center of Integrative Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Kathryn R Lallinger
- Duke Clinical Research Institute, and.,Duke Evidence-Based Practice Center, Durham, North Carolina; and
| | - Samantha E Bowen
- Duke Center for Autism and Brain Development, School of Medicine, Duke University, Durham, North Carolina
| | | | - Amanda J McBroom
- Duke Clinical Research Institute, and.,Duke Evidence-Based Practice Center, Durham, North Carolina; and
| | - Gillian D Sanders
- Duke Clinical Research Institute, and.,Duke Evidence-Based Practice Center, Durham, North Carolina; and
| | - Alex R Kemper
- Division of Ambulatory Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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20
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Portnoy J, Raine A, Liu J, Hibbeln JR. Reductions of intimate partner violence resulting from supplementing children with omega-3 fatty acids: A randomized, double-blind, placebo-controlled, stratified, parallel-group trial. Aggress Behav 2018; 44:491-500. [PMID: 29781086 DOI: 10.1002/ab.21769] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 12/14/2022]
Abstract
Omega-3 supplementation has been found to reduce externalizing behavior in children. Reciprocal models of parent-child behavior suggest that improving child behavior could lead to improvements in parent behavior, however no study has examined whether omega-3 supplementation in children could reduce intimate partner violence or child maltreatment by their adult caregivers. In this randomized, double-blind, placebo-controlled, stratified, parallel group trial, a community sample of children were randomized to receive either a fruit drink containing 1 gm of omega-3 fats (Smartfish Recharge; Omega-3 group, n = 100) or the same fruit drink without omega-3's (Placebo group, n = 100). Child participants, adult caregivers, and research staff were blinded to group assignment. Adult caregivers reported inter-partner and child-directed physical assault and psychological aggression at baseline, 6 months (end of treatment) and 12 months (6 months post-treatment) using the Conflicts Tactics Scale. Caregivers of children in the omega-3 group reported long-term reductions in psychological aggression in a group × time interaction. Improvements in adult psychological aggression were correlated with improvements in child externalizing behavior scores. No differences were reported for child maltreatment. This study is the first to show that omega-3 supplementation in children can reduce inter-partner psychological aggression among adult caregivers not receiving supplements. Findings suggest that improving child behavior through omega-3 supplementation could have long-term benefits to the family system as a whole.
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Affiliation(s)
- Jill Portnoy
- School of Criminology and Justice Studies, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Adrian Raine
- Departments of Criminology, Psychiatry, and Psychology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jianghong Liu
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Hibbeln
- Section on Nutritional Neuroscience, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
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Cornu C, Mercier C, Ginhoux T, Masson S, Mouchet J, Nony P, Kassai B, Laudy V, Berquin P, Franc N, Le Heuzey MF, Desombre H, Revol O. A double-blind placebo-controlled randomised trial of omega-3 supplementation in children with moderate ADHD symptoms. Eur Child Adolesc Psychiatry 2018; 27:377-384. [PMID: 28993963 DOI: 10.1007/s00787-017-1058-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Clinical trials and inconclusive meta-analyses have investigated the effects of omega-3 supplements in children with Attention-Deficit Hyperactivity Disorder (ADHD). We performed a randomised placebo-controlled trial to evaluate the efficacy of omega-3 fatty acids. METHODS Children aged 6-15 years with established diagnosis of ADHD were randomised 1:1 to receive either supplements containing docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) or a placebo for 3 months. Psychotropic or omega-3-containing treatments were not authorised during the study. The primary outcome was the change in the Attention-Deficit Hyperactivity Disorder Rating Scale version 4 (ADHD-RS-IV). Other outcomes included safety, lexical level (Alouette test), attention (Test of Attentional Performance for Children-KiTAP), anxiety (48-item Conners Parent Rating Scale-Revised-CPRS-R), and depression (Children's Depression Inventory-CDI). RESULTS Between 2009 and 2011, 162 children were included in five French child psychiatry centres. The mean age was 9.90 (SD 2.62) years and 78.4% were boys. The inclusion ADHD-RS-IV at was 37.31 (SD 8.40). The total ADHD-RS-IV score reduction was greater in the placebo group than in the DHA-EPA group: -19 (-26, -12) % and -9.7 (-16.6, -2.9) %, respectively, p = 0.039. The other components of the Conners score had a similar variation but the differences between groups were not significant. Two patients in the DHA-EPA group and none in the placebo group experienced a severe adverse event (hospitalisation for worsening ADHD symptoms). CONCLUSION This study did not show any beneficial effect of omega-3 supplement in children with mild ADHD symptoms.
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Affiliation(s)
- Catherine Cornu
- INSERM, CIC1407, 69500, Bron, France. .,Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Equipe EME, 69100, Lyon, France. .,Service de Pharmacologie Clinique, Hospices Civils de Lyon, 69500, Bron, France. .,Centre d'Investigation Clinique - Hôpital Louis Pradel, 28, Avenue du Doyen Lépine, 69500, Bron, France.
| | - Catherine Mercier
- Université Claude Bernard Lyon 1, 69100, Lyon, France.,Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, 69003, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, CNRS, UMR 5558, 69100, Villeurbanne, France
| | | | | | - Julie Mouchet
- Université Claude Bernard Lyon 1, 69100, Lyon, France
| | - Patrice Nony
- Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Equipe EME, 69100, Lyon, France.,Service de Pharmacologie Clinique, Hospices Civils de Lyon, 69500, Bron, France
| | - Behrouz Kassai
- INSERM, CIC1407, 69500, Bron, France.,Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Equipe EME, 69100, Lyon, France.,Service de Pharmacologie Clinique, Hospices Civils de Lyon, 69500, Bron, France
| | | | - Patrick Berquin
- Service de Neurologie Pédiatrique, Hôpital Nord, 80054, Amiens, France
| | - Nathalie Franc
- Service de Médecine Psychologique Enfants et Adolescents, Hôpital Saint-Eloi, 34295, Montpellier, France
| | - Marie-France Le Heuzey
- Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Robert Debré, 75935, Paris, France
| | - Hugues Desombre
- Unité de Psychologie Médicale et de Liaison, Hôpital femme-Mère-Enfant, 69500, Bron, France
| | - Olivier Revol
- Service de Psychopathologie de l'enfant et de l'adolescent, Hôpital Pierre Wertheimer, 69500, Bron, France
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Omega-3 Polyunsaturated Fatty Acids in Youths with Attention Deficit Hyperactivity Disorder: a Systematic Review and Meta-Analysis of Clinical Trials and Biological Studies. Neuropsychopharmacology 2018; 43:534-545. [PMID: 28741625 PMCID: PMC5669464 DOI: 10.1038/npp.2017.160] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/03/2017] [Accepted: 07/18/2017] [Indexed: 12/27/2022]
Abstract
The role of omega-3 polyunsaturated fatty acids (omega-3 or n-3 PUFAs) in the pathogenesis and treatment of children and adolescents with attention deficit hyperactivity disorder (ADHD) is unclear. A systematic review followed by meta-analysis was conducted on: (1) randomized controlled trials (RCTs) assessing the effects of n-3 PUFAs on clinical symptoms and cognition in children and adolescent with ADHD; and (2) case-control studies assessing the levels of n-3 PUFAs in blood and buccal tissues of children and adolescents with ADHD. In seven RCTs, totalling n=534 randomized youth with ADHD, n-3 PUFAs supplementation improves ADHD clinical symptom scores (g=0.38, p<0.0001); and in three RCTs, totalling n=214 randomized youth with ADHD, n-3 PUFAs supplementation improves cognitive measures associated with attention (g=1.09, p=0.001). Moreover, children and adolescents with ADHD have lower levels of DHA (seven studies, n=412, g=-0.76, p=0.0002), EPA (seven studies, n=468, g=-0.38, p=0.0008), and total n-3 PUFAs (six studies, n=396, g=-0.58, p=0.0001). In summary, there is evidence that n-3 PUFAs supplementation monotherapy improves clinical symptoms and cognitive performances in children and adolescents with ADHD, and that these youth have a deficiency in n-3 PUFAs levels. Our findings provide further support to the rationale for using n-3 PUFAs as a treatment option for ADHD.
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Agostoni C, Nobile M, Ciappolino V, Delvecchio G, Tesei A, Turolo S, Crippa A, Mazzocchi A, Altamura CA, Brambilla P. The Role of Omega-3 Fatty Acids in Developmental Psychopathology: A Systematic Review on Early Psychosis, Autism, and ADHD. Int J Mol Sci 2017; 18:E2608. [PMID: 29207548 PMCID: PMC5751211 DOI: 10.3390/ijms18122608] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/24/2017] [Accepted: 11/27/2017] [Indexed: 12/24/2022] Open
Abstract
In this systematic review, we will consider and debate studies that have explored the effects of ω-3 polyunsaturated fatty acids (PUFAs) in three major, and somehow related, developmental psychiatric disorders: Autism, Attention Deficit and Hyperactivity disorder and Psychosis. The impact of ω-3 PUFAs on clinical symptoms and, if possible, brain trajectory in children and adolescents suffering from these illnesses will be reviewed and discussed, considering the biological plausibility of the effects of omega-3 fatty acids, together with their potential perspectives in the field. Heterogeneity in study designs will be discussed in the light of differences in results and interpretation of studies carried out so far.
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Affiliation(s)
- Carlo Agostoni
- Pediatric Intermediate Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ospedale Cà Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
- SIGENP (Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition), via Libero Temolo 4 (Torre U8), 20126 Milan, Italy.
| | - Maria Nobile
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, via Don Luigi Monza 20, Bosisio Parini, 23842 Lecco, Italy.
| | - Valentina Ciappolino
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ospedale Cà Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
| | - Giuseppe Delvecchio
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ospedale Cà Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
| | - Alessandra Tesei
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, via Don Luigi Monza 20, Bosisio Parini, 23842 Lecco, Italy.
| | - Stefano Turolo
- Pediatric Nephrology & Dialysis, Milano Fondazione IRCCS Cà Grande Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
| | - Alessandro Crippa
- Child Psychopathology Unit, Scientific Institute, IRCCS Eugenio Medea, via Don Luigi Monza 20, Bosisio Parini, 23842 Lecco, Italy.
| | - Alessandra Mazzocchi
- Pediatric Intermediate Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ospedale Cà Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
| | - Carlo A Altamura
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ospedale Cà Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
| | - Paolo Brambilla
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ospedale Cà Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy.
- Department of Psychiatry and Behavioural Neurosciences, University of Texas at Houston, Houston, 77021 TX, USA.
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Abstract
EPA and DHA appear to be the most important n-3 fatty acids, but roles for n-3 docosapentaenoic acid are now also emerging. Intakes of EPA and DHA are usually low, typically below those recommended. Increased intakes result in higher concentrations of EPA and DHA in blood lipids, cells and tissues. Increased content of EPA and DHA modifies the structure of cell membranes and the function of membrane proteins. EPA and DHA modulate the production of lipid mediators and through effects on cell signalling can alter the patterns of gene expression. Through these mechanisms, EPA and DHA alter cell and tissue responsiveness in a way that often results in more optimal conditions for growth, development and maintenance of health. DHA has vital roles in brain and eye development and function. EPA and DHA have a wide range of physiological roles, which are linked to certain health or clinical benefits, particularly related to CVD, cancer, inflammation and neurocognitive function. The benefits of EPA and DHA are evident throughout the life course. Future research will include better identification of the determinants of variation of responses to increased intake of EPA and DHA; more in-depth dose-response studies of the effects of EPA and DHA; clearer identification of the specific roles of EPA, docosapentaenoic acid and DHA; testing strategies to enhance delivery of n-3 fatty acids to the bloodstream; and exploration of sustainable alternatives to fish-derived very long-chain n-3 fatty acids.
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The potential relevance of docosahexaenoic acid and eicosapentaenoic acid to the etiopathogenesis of childhood neuropsychiatric disorders. Eur Child Adolesc Psychiatry 2017; 26:1011-1030. [PMID: 27988864 DOI: 10.1007/s00787-016-0932-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 12/05/2016] [Indexed: 02/07/2023]
Abstract
Over the last 15 years, considerable interest has been given to the potential role of omega-3 polyunsaturated fatty acids (PUFAs) for understanding pathogenesis and treatment of neurodevelopmental and psychiatric disorders. This review aims to systematically investigate the scientific evidence supporting the hypothesis on the omega-3 PUFAs deficit as a risk factor shared by different pediatric neuropsychiatric disorders. Medline PubMed database was searched for studies examining blood docosahexaenoic acid (DHA) or eicosapentaenoic acid (EPA) status in children with neuropsychiatric disorders. Forty-one published manuscripts were compatible with the search criteria. The majority of studies on attention-deficit/hyperactivity disorder (ADHD) and autism found a significant decrease in DHA levels in patients versus healthy controls. For the other conditions examined-depression, juvenile bipolar disorder, intellectual disabilities, learning difficulties, and eating disorders (EDs)-the literature was too limited to draw any stable conclusions. However, except EDs, findings in these conditions were in line with results from ADHD and autism studies. Results about EPA levels were too inconsistent to conclude that EPA could be associated with any of the conditions examined. Finally, correlational data provided, on one hand, evidence for a negative association between DHA and symptomatology, whereas on the other hand, evidence for a positive association between EPA and emotional well-being. Although the present review underlines the potential involvement of omega-3 PUFAs in the predisposition to childhood neuropsychiatric disorders, more observational and intervention studies across different diagnoses are needed, which should integrate the collection of baseline PUFA levels with their potential genetic and environmental influencing factors.
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Do Omega-3/6 Fatty Acids Have a Therapeutic Role in Children and Young People with ADHD? J Lipids 2017; 2017:6285218. [PMID: 28951787 PMCID: PMC5603098 DOI: 10.1155/2017/6285218] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/08/2017] [Indexed: 12/01/2022] Open
Abstract
Background Attention deficit hyperactivity disorder (ADHD) is a debilitating behavioural disorder affecting daily ability to function, learn, and interact with peers. This publication assesses the role of omega-3/6 fatty acids in the treatment and management of ADHD. Methods A systematic review of 16 randomised controlled trials was undertaken. Trials included a total of 1,514 children and young people with ADHD who were allocated to take an omega-3/6 intervention, or a placebo. Results Of the studies identified, 13 reported favourable benefits on ADHD symptoms including improvements in hyperactivity, impulsivity, attention, visual learning, word reading, and working/short-term memory. Four studies used supplements containing a 9 : 3 : 1 ratio of eicosapentaenoic acid : docosahexaenoic acid : gamma linolenic acid which appeared effective at improving erythrocyte levels. Supplementation with this ratio of fatty acids also showed promise as an adjunctive therapy to traditional medications, lowering the dose and improving the compliance with medications such as methylphenidate. Conclusion ADHD is a frequent and debilitating childhood condition. Given disparaging feelings towards psychostimulant medications, omega-3/6 fatty acids offer great promise as a suitable adjunctive therapy for ADHD.
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Moghaddam MF, Shamekhi M, Rakhshani T. Effectiveness of methylphenidate and PUFA for the treatment of patients with ADHD: A double-blinded randomized clinical trial. Electron Physician 2017; 9:4412-4418. [PMID: 28713515 PMCID: PMC5498708 DOI: 10.19082/4412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/16/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In some children with ADHD, sub-optimal levels of various nutrients including PUFA especially omega-3 has been observed, and contradictory reports exist on the results of studies conducted on the positive therapeutic effects of PUFA in patients with ADHD. OBJECTIVE The aim of this study was to investigate the effectiveness of methylphenidate and PUFA on treatment of patients with ADHD in Zahedan, Iran. METHODS In this clinical trial, 40 children between 6 and 12 years of age with ADHD were investigated in Zahedan in 2014. Patients were randomly divided into two groups of methylphenidate plus PUFA and methylphenidate plus placebo. ADHD rating scale was filled before and after the study for patients of both groups. Finally, data were analyzed using SPSS18, paired-samples t-test and chi-square. RESULTS Mean age of patients was 2.9±1.8 years. Thirty-three children (82.5%) were boys and seven children (17.5%) were girls. Mean severity of signs in the group under methylphenidate plus PUFA treatment was 39.9±4.9 before treatment and 20.1±6.0 after 8 weeks of treatment (p<0.001). Mean severity of signs in the group under methylphenidate plus placebo treatment was 41.2±2.7 before treatment and 26.1±9.0 after 8 weeks of treatment (p<0.001). Mean reduction in the severity of symptoms in the group under methylphenidate therapy was 19.7±5.9 and in PUFA and placebo group it was 15.1±9.3 (p<0.067). Response to treatment (a reduction of at least 25% in the signs) in the group taking methylphenidate plus PUFA was 90% (18 patients) and in methylphenidate plus placebo group, it was 60% (12 patients) (p=0.028). CONCLUSION This study shows that PUFA is an efficient nutrient to treat ADHD and it can be used to treat patients. However, definitive conclusion requires repeating the study with a larger sample and longer study period. TRIAL REGISTRATION The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2015092724209N2. FUNDING The authors received no financial support for the research, authorship, and/or publication of this article.
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Affiliation(s)
- Mahbobeh Firouzkouhi Moghaddam
- M.D. of Psychiatry, Assistant Professor, Research Center for Children and Adolescent Health, Department of Children and Adolescent Psychiatry, Zahedan University of Medical Science, Zahedan, Iran
| | - Maryam Shamekhi
- M.D., Assistant of Psychiatry, Department of Children and Adolescent Psychiatry, Zahedan University of Medical Science, Iran
| | - Tayebeh Rakhshani
- M.D., Assistant Professor of Health Education & Promotion, Nutrition Research Center, Department Of Public Health, School of Health, Shiraz University of Medical Science, Iran
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A Review of Recruitment, Adherence and Drop-Out Rates in Omega-3 Polyunsaturated Fatty Acid Supplementation Trials in Children and Adolescents. Nutrients 2017; 9:nu9050474. [PMID: 28489030 PMCID: PMC5452204 DOI: 10.3390/nu9050474] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/26/2017] [Accepted: 05/02/2017] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The influence of n-3 long-chain polyunsaturated fatty acids (n-3 LCPUFA) supplementation on health outcomes has been studied extensively with randomized controlled trials (RCT). In many research fields, difficulties with recruitment, adherence and high drop-out rates have been reported. However, what is unknown is how common these problems are in n-3 LCPUFA supplementation studies in children and adolescents. Therefore, this paper will review n-3 LCPUFA supplementation studies in children and adolescents with regard to recruitment, adherence and drop-out rates. METHODS The Web of Science, PubMed and Ovid databases were searched for papers reporting on RCT supplementing children and adolescents (2-18 years) with a form of n-3 LCPUFA (or placebo) for at least four weeks. As a proxy for abiding to CONSORT guidelines, we noted whether manuscripts provided a flow-chart and provided dates defining the period of recruitment and follow-up. RESULTS Ninety manuscripts (reporting on 75 studies) met the inclusion criteria. The majority of the studies did not abide by the CONSORT guidelines: 55% did not provide a flow-chart, while 70% did not provide dates. The majority of studies provided minimal details about the recruitment process. Only 25 of the 75 studies reported an adherence rate which was on average 85%. Sixty-five of the 75 studies included drop-out rates which were on average 17%. CONCLUSION Less than half of the included studies abided by the CONSORT guidelines (45% included a flow chart, while 30% reported dates). Problems with recruitment and drop-out seem to be common in n-3 LCPUFA supplementation trials in children and adolescents. However, reporting about recruitment, adherence and dropout rates was very heterogeneous and minimal in the included studies. Some techniques to improve recruitment, adherence and dropout rates were identified from the literature, however these techniques may need to be tailored to n-3 LCPUFA supplementation studies in children and adolescents.
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Gajos JM, Beaver KM. The effect of omega-3 fatty acids on aggression: A meta-analysis. Neurosci Biobehav Rev 2016; 69:147-58. [DOI: 10.1016/j.neubiorev.2016.07.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 06/09/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
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Raine A, Cheney RA, Ho R, Portnoy J, Liu J, Soyfer L, Hibbeln J, Richmond TS. Nutritional supplementation to reduce child aggression: a randomized, stratified, single-blind, factorial trial. J Child Psychol Psychiatry 2016; 57:1038-46. [PMID: 27166583 DOI: 10.1111/jcpp.12565] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND While some studies suggest that nutritional supplementation may reduce aggressive behavior in children, they have not examined whether its efficacy may be enhanced in conjunction with other treatment approaches. This study tests the hypothesis that a nutritional supplementation of omega-3, multivitamins, and minerals over 3 months, combined with cognitive behavior therapy, will reduce childhood aggression. METHODS In this randomized, single-blind, stratified, factorial trial, a high-risk community sample of 290 children aged 11-12 years were randomized into Nutrition only, cognitive behavioral therapy (CBT) only, Nutrition + CBT, and Control groups. The primary outcome measures of child- and parent-reported aggressive and antisocial behavior were collected at 0 months (baseline), 3 months (end of treatment), 6 months (3 months posttreatment), and 12 months (9 months posttreatment). The trial ('Healthy Brains & Behavior: Understanding and Treating Youth Aggression (HBB)' was registered at ClinicalTrials.gov at https://clinicaltrials.gov/ct2/show/NCT00842439 RESULTS: For child self-reports, children in the Nutrition only group showed reduced externalizing behavior compared to Controls at 3 months. At 6 months, the Nutrition + CBT group scored lower on externalizing behavior compared to both CBT only and Control groups. Findings were more in evidence for an Aggressive-Reactive form of antisocial behavior than for a Callous-Proactive form. Effect sizes were in the small-to-medium range (d = -.33 to -.37). Group differences were not sustained 9 months posttreatment, and no other effects were significant. CONCLUSIONS Findings provide some limited support for the efficacy of omega-3, vitamin, and mineral supplementation in reducing aggressive behavior in children, and represent the first evaluation of nutritional supplements in conjunction with CBT.
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Affiliation(s)
- Adrian Raine
- Departments of Criminology, Psychiatry, and Psychology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rose A Cheney
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ringo Ho
- Division of Psychology, Nanyang Technological University, Singapore City, Singapore
| | - Jill Portnoy
- Department of Criminology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jianghong Liu
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Liana Soyfer
- Department of Criminology, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph Hibbeln
- Section on Nutritional Neuroscience, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
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Anand P, Sachdeva A. Effect of Poly Unsaturated Fatty Acids Administration on Children with Attention Deficit Hyperactivity Disorder: A Randomized Controlled Trial. J Clin Diagn Res 2016; 10:OC01-OC05. [PMID: 27790483 DOI: 10.7860/jcdr/2016/20423.8471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Attention Deficit Hyperactivity Disorder (ADHD) is a common disorder of childhood. Studies have indicated nutritional deficiencies, particularly Poly Unsaturated Fatty Acids (PUFA) deficiency in these children and have suggested supplementation with PUFA for clinical improvement. AIM The present study aimed at evaluating the effect of PUFA administration in Indian children with ADHD. SETTINGS AND DESIGN The study was conducted in the paediatrics and psychiatry departments of a tertiary care hospital. We conducted a prospective double blind randomized control trial on children aged 4-11 years, diagnosed with ADHD according to DSM-IV TR criterias and Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and lifetime version. MATERIALS AND METHODS The study subjects were randomized into study and control groups. The control group was administered Atomoxetine, while the study group received Atomoxetine along with Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA). Both groups were followed up every 2 weeks over the next 4 months using Conner's Parent Rating Scale - Revised (CPRS-R). STATISTICAL ANALYSIS The data was carefully analysed by SPSS (17th version) software with the help of a statistician. Confidence interval of 95% was used. The complete data was analysed using appropriate parametric and non parametric tests. Correlation was done between various socio-demographic and illness related parameters. For all analyses, probability of 5% or less was assumed to represent statistical significance. RESULTS Fifty children diagnosed with ADHD were randomized to study group (n=25) and control group (n=25). The study group had greater reduction in ADHD scores as compared to the control group, although not statistically significant (p = 0.08). Improvement was more significant in male study subjects with combined type of ADHD. CONCLUSION It may be concluded that PUFA supplementation improves the symptoms of ADHD. However, the effect is not clinically significant if supplementation is not given for prolonged duration and in adequate doses.
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Affiliation(s)
- Puneet Anand
- Senior Resident, Department of Pediatrics, ESIC Medical College and Hospital , Faridabad, Haryana, India
| | - Ankur Sachdeva
- Assistant Professor, Department of Psychiatry, ESIC Medical College and Hospital , Faridabad, Haryana, India
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Park SY, Lee SI, Lee MS. Review on the Efficacy of Omega-3 in the Treatment of Attention-Deficit Hyperactivity Disorder. Soa Chongsonyon Chongsin Uihak 2016. [DOI: 10.5765/jkacap.2016.27.1.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- So-Young Park
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Moon-Soo Lee
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
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The effect of omega-3 polyunsaturated fatty acid supplementation on emotional dysregulation, oppositional behaviour and conduct problems in ADHD: A systematic review and meta-analysis. J Affect Disord 2016; 190:474-482. [PMID: 26551407 DOI: 10.1016/j.jad.2015.09.053] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/26/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND A number of randomised controlled trials report a beneficial effect of omega-3 polyunsaturated fatty acid (n-3 PUFA) supplementation on emotional lability (EL) and related domains (e.g. oppositional behaviour, conduct problems). Given that n-3 PUFA supplementation shows a significant effect on reducing symptoms of attention-deficit/hyperactivity disorder (ADHD) and that EL and related behaviours commonly co-occurs with ADHD, it is important that there is a more conclusive picture as to the effect of n-3 PUFA on these co-occurring clinical domains. METHODS Databases (Ovid Medline, Embase, Psychinfo) were searched for trials assessing the effects of n-3 PUFA on EL, oppositional behaviour, aggression and conduct problems. We included trials in children who had ADHD or a related neurodevelopmental disorder. RESULTS Of the 1775 identified studies, 10 were included in the meta-analysis. In the primary analyses n-3 PUFA supplementation did not show improvements in measures of EL, oppositional behaviour, conduct problems or aggression. However subgroup analyses of higher quality studies and those meeting strict inclusion criteria found a significant reduction in EL and oppositional behaviour. LIMITATIONS A number of treatment effects may have failed to reach statistical significance due to small sample sizes and within and between study heterogeneity in terms of design and study participants. CONCLUSIONS These results exclude the possibility of moderate to large effects. They provide suggestive evidence of small effects of n-3 PUFA on reducing EL and oppositional behaviour in subgroups of children with ADHD.
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Königs A, Kiliaan AJ. Critical appraisal of omega-3 fatty acids in attention-deficit/hyperactivity disorder treatment. Neuropsychiatr Dis Treat 2016; 12:1869-82. [PMID: 27555775 PMCID: PMC4968854 DOI: 10.2147/ndt.s68652] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder. The classical treatment of ADHD where stimulant medication is used has revealed severe side effects and intolerance. Consequently, the demand to search for alternative treatment has increased rapidly. When comparing levels of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) in ADHD patients with those in age-matching controls, lower levels are found in ADHD patients' blood. ω-3 PUFAs are essential nutrients and necessary for a proper brain function and development. Additionally, there are strong indications that ω-3 PUFA supplements could have beneficial effects on ADHD. However, the results of ω-3 PUFA supplementation studies show a high variability. Therefore, we reviewed recent studies published between 2000 and 2015 to identify effective treatment combinations, the quality of design, and safety and tolerability of ω-3-containing food supplements. We searched the databases MEDLINE, PubMed, and Web of Science with keywords such as "ADHD" and "ω-3/6 PUFA" and identified 25 studies that met the inclusion and exclusion criteria. The results of these ω-3 PUFA studies are contradictory but, overall, show evidence for a successful treatment of ADHD symptoms. Tolerability of the given supplements was high, and only mild side effects were reported. In conclusion, there is evidence that a ω-3 PUFA treatment has a positive effect on ADHD. It should be added that treatment could be more effective in patients with mild forms of ADHD. Moreover, the dosage of stimulant medication could be reduced when used in combination with ω-3 PUFA supplements. Further studies are necessary to investigate underlying mechanisms that can lead to a reduction of ADHD symptoms due to ω-3 PUFA treatments and also to determine the optimal concentrations of ω-3 PUFAs, whether used as single treatment or in combination with other medication.
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Affiliation(s)
- Anja Königs
- Department of Anatomy, Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Amanda J Kiliaan
- Department of Anatomy, Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
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A randomised double-blind placebo-controlled trial investigating the behavioural effects of vitamin, mineral and n-3 fatty acid supplementation in typically developing adolescent schoolchildren. Br J Nutr 2015; 115:361-73. [PMID: 26573368 DOI: 10.1017/s0007114515004390] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Nutrient deficiencies have been implicated in anti-social behaviour in schoolchildren; hence, correcting them may improve sociability. We therefore tested the effects of vitamin, mineral and n-3 supplementation on behaviour in a 12-week double-blind randomised placebo-controlled trial in typically developing UK adolescents aged 13-16 years (n 196). Changes in erythrocyte n-3 and 6 fatty acids and some mineral and vitamin levels were measured and compared with behavioural changes, using Conners' teacher ratings and school disciplinary records. At baseline, the children's PUFA (n-3 and n-6), vitamin and mineral levels were low, but they improved significantly in the group treated with n-3, vitamins and minerals (P=0·0005). On the Conners disruptive behaviour scale, the group given the active supplements improved, whereas the placebo group worsened (F=5·555, d=0·35; P=0·02). The general level of disciplinary infringements was low, thus making it difficult to obtain improvements. However, throughout the school term school disciplinary infringements increased significantly (by 25 %; Bayes factor=115) in both the treated and untreated groups. However, when the subjects were split into high and low baseline infringements, the low subset increased their offences, whereas the high-misbehaviour subset appeared to improve after treatment. But it was not possible to determine whether this was merely a statistical artifact. Thus, when assessed using the validated and standardised Conners teacher tests (but less clearly when using school discipline records in a school where misbehaviour was infrequent), supplementary nutrition might have a protective effect against worsening behaviour.
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Reduced Symptoms of Inattention after Dietary Omega-3 Fatty Acid Supplementation in Boys with and without Attention Deficit/Hyperactivity Disorder. Neuropsychopharmacology 2015; 40:2298-306. [PMID: 25790022 PMCID: PMC4538345 DOI: 10.1038/npp.2015.73] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/17/2014] [Accepted: 03/10/2015] [Indexed: 02/03/2023]
Abstract
Attention deficit/hyperactivity disorder (ADHD) is one of the most common child psychiatric disorders, and is often treated with stimulant medication. Nonpharmacological treatments include dietary supplementation with omega-3 fatty acids, although their effectiveness remains to be shown conclusively. In this study, we investigated the effects of dietary omega-3 fatty acid supplementation on ADHD symptoms and cognitive control in young boys with and without ADHD. A total of 40 boys with ADHD, aged 8-14 years, and 39 matched, typically developing controls participated in a 16-week double-blind randomized placebo-controlled trial. Participants consumed 10 g of margarine daily, enriched with either 650 mg of eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) each or placebo. Baseline and follow-up assessments addressed ADHD symptoms, fMRI of cognitive control, urine homovanillic acid, and cheek cell phospholipid sampling. EPA/DHA supplementation improved parent-rated attention in both children with ADHD and typically developing children. Phospholipid DHA level at follow-up was higher for children receiving EPA/DHA supplements than placebo. There was no effect of EPA/DHA supplementation on cognitive control or on fMRI measures of brain activity. This study shows that dietary supplementation with omega-3 fatty acids reduces symptoms of ADHD, both for individuals with ADHD and typically developing children. This effect does not appear to be mediated by cognitive control systems in the brain, as no effect of supplementation was found here. Nonetheless, this study offers support that omega-3 supplementation may be an effective augmentation for pharmacological treatments of ADHD (NCT01554462: The Effects of EPA/DHA Supplementation on Cognitive Control in Children with ADHD; http://clinicaltrials.gov/show/NCT01554462).
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Calder PC. Functional Roles of Fatty Acids and Their Effects on Human Health. JPEN J Parenter Enteral Nutr 2015; 39:18S-32S. [PMID: 26177664 DOI: 10.1177/0148607115595980] [Citation(s) in RCA: 558] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 06/03/2015] [Indexed: 12/18/2022]
Abstract
A variety of fatty acids exists in the diet of humans, in the bloodstream of humans, and in cells and tissues of humans. Fatty acids are energy sources and membrane constituents. They have biological activities that act to influence cell and tissue metabolism, function, and responsiveness to hormonal and other signals. The biological activities may be grouped as regulation of membrane structure and function; regulation of intracellular signaling pathways, transcription factor activity, and gene expression; and regulation of the production of bioactive lipid mediators. Through these effects, fatty acids influence health, well-being, and disease risk. The effects of saturated, cis monounsaturated, ω-6 and ω-3 polyunsaturated, and trans fatty acids are discussed. Although traditionally most interest in the health impact of fatty acids related to cardiovascular disease, it is now clear that fatty acids influence a range of other diseases, including metabolic diseases such as type 2 diabetes, inflammatory diseases, and cancer. Scientists, regulators, and communicators have described the biological effects and the health impacts of fatty acids according to fatty acid class. However, it is now obvious that within any fatty acid class, different members have different actions and effects. Thus, it would seem more appropriate to describe biological effects and health impacts of individual named fatty acids, although it is recognized that this would be a challenge when communicating outside of an academic environment (eg, to consumers).
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Affiliation(s)
- Philip C Calder
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom National Institute of Health Research Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton General Hospital, Southampton, United Kingdom Department of Biological Sciences, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
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Cooper RE, Tye C, Kuntsi J, Vassos E, Asherson P. Omega-3 polyunsaturated fatty acid supplementation and cognition: A systematic review and meta-analysis. J Psychopharmacol 2015; 29:753-63. [PMID: 26040902 DOI: 10.1177/0269881115587958] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Omega-3 polyunsaturated fatty acids (n-3 PUFAs) are promoted as cognitive enhancers with consumption recommended in the general population and those with neurocognitive deficits such as attention deficit hyperactivity disorder (ADHD). However, evidence from randomised placebo-controlled trials is inconclusive. AIMS This study aimed to conduct a systematic review and meta-analysis examining the effect of n-3 PUFA supplementation on cognition in healthy populations and those with ADHD and related disorders (RDs). METHODS Databases were searched for randomised controlled trials (RCTs) in adults and school-aged children (who were healthy and typically developing (TD) or had ADHD or a related-neurodevelopmental disorder (ADHD+RD) which assessed the effects of n-3 PUFA on cognition. RESULTS In the 24 included studies n-3 PUFA supplementation, in the whole sample and the TD and ADHD+RD subgroup, did not show improvements in any of the cognitive performance measures. In those with low n-3 PUFA status, supplementation improved short-term memory. CONCLUSIONS There is marginal evidence that n-3 PUFA supplementation effects cognition in those who are n-3 PUFA deficient. However, there is no evidence of an effect in the general population or those with neurodevelopmental disorders. This has important implications given the widespread advertisement and consumption of n-3 PUFA; claims of cognitive benefit should be narrowed.
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Affiliation(s)
- Ruth E Cooper
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, London London, UK
| | - Charlotte Tye
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, London London, UK
| | - Jonna Kuntsi
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, London London, UK
| | - Evangelos Vassos
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, London London, UK
| | - Philip Asherson
- King's College London, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, London London, UK
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Abstract
PURPOSE OF REVIEW This article provides an overview of current controversies in attention-deficit/hyperactivity disorder (ADHD) research, with an emphasis on recent findings that are directly relevant to clinical practice. RECENT FINDINGS Over the past few years, a number of studies have added key evidence to ongoing debates about the epidemiology, nosology, and treatment of ADHD. Although the causes of the rising prevalence of ADHD in the USA are still not fully understood, recent research suggests that environmental factors and changes to the diagnostic criteria may have played a role. In addition, there continues to be controversy surrounding the clinical diagnosis of ADHD and newly recognized, related conditions such as sluggish cognitive tempo. Recent studies have also challenged previous assumptions about the long-term effects of stimulant treatment on growth, academic achievement, and substance use. Moreover, although most complementary and alternative therapies for ADHD appear to be ineffective, there is emerging evidence supporting the value of fatty acid supplementation. Although these findings are promising, more research is needed on all fronts. SUMMARY Although research has shed light on unanswered questions about the epidemiology, nosology, and treatment of ADHD, much is still not known. An understanding of the most important current controversies in ADHD research may aid pediatricians in clinical decision making and allow them to counsel patients more effectively.
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Raine A, Portnoy J, Liu J, Mahoomed T, Hibbeln J. Reduction in behavior problems with omega-3 supplementation in children aged 8-16 years: a randomized, double-blind, placebo-controlled, stratified, parallel-group trial. J Child Psychol Psychiatry 2015; 56:509-20. [PMID: 25146492 PMCID: PMC4336833 DOI: 10.1111/jcpp.12314] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND While limited evidence suggests that omega-3 supplementation may reduce antisocial behavior in children, studies have not reported on posttreatment follow-up and most treatment periods have been of short duration. This study tests the hypothesis that omega-3 supplementation over 6 months will reduce behavior problems in children both at the end of treatment and at 6 months post treatment. METHODS In this randomized, double-blind, placebo-controlled, stratified, parallel-group trial, a community sample of 8-16 year old children were randomized into a treatment group (N = 100) and a placebo-control group (N = 100). The supplementation consisted of a fruit drink containing 1 g/day of omega-3 or a placebo consisting of the same fruit drink without omega-3. Participants, caregivers, and research assistants were blinded to group assignment. The primary outcome measures of externalizing and internalizing behavior problems were reported by both caregivers and their children in a laboratory setting at 0 months (baseline), 6 months (end of treatment) and 12 months (6 months post treatment), together with the secondary outcome measures of parental antisocial behavior. Data were analyzed on an intention-to-treat basis including all participants. TRIAL REGISTRATION ClinicalTrials.gov: http://clinicaltrials.gov/ct2/show/NCT02016079?term=mauritius&rank=2 RESULTS: Significant group × time interactions were observed with the treatment group showing long-term improvements in child behavior problems. The average posttreatment effect size was d = -.59. Effects were documented for parent reports, but with the exception of proactive and reactive aggression, child-report data were nonsignificant. Parents whose children took omega-3 showed significant posttreatment reductions in their own antisocial and aggressive behavior. This improvement in caregiver behavior partly mediated the improvements observed in child behavior. CONCLUSIONS Findings provide initial evidence that omega-3 supplementation can produce sustained reductions in externalizing and internalizing behavior problems. Results are the first to report improvements in caregiver behavior, and to establish this improvement as a part-mechanism for the efficacy of omega-3.
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Affiliation(s)
- Adrian Raine
- Departments of Criminology, Psychiatry, and Psychology, University of Pennsylvania
| | - Jill Portnoy
- Departments of Criminology, Psychiatry, and Psychology, University of Pennsylvania
| | | | | | - Joseph Hibbeln
- Section on Nutritional Neuroscience, National Institute on Alcohol Abuse and Alcoholism
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Heilskov Rytter MJ, Andersen LBB, Houmann T, Bilenberg N, Hvolby A, Mølgaard C, Michaelsen KF, Lauritzen L. Diet in the treatment of ADHD in children - a systematic review of the literature. Nord J Psychiatry 2015; 69:1-18. [PMID: 24934907 DOI: 10.3109/08039488.2014.921933] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric conditions in childhood. Dietary changes have been suggested as a way of reducing ADHD symptoms. AIMS To provide an overview of the evidence available on dietary interventions in children with ADHD, a systematic review was carried out of all dietary intervention studies in children with ADHD. METHODS Relevant databases were searched in October 2011, with an update search in March 2013. The studies included describe diet interventions in children with ADHD or equivalent diagnoses measuring possible changes in core ADHD symptoms: inattention, hyperactivity and impulsivity. RESULTS A total of 52 studies were identified, some investigating whether ADHD symptoms can improve by avoiding certain food elements (20 studies), and some whether certain food elements may reduce ADHD symptoms (32 studies). CONCLUSION Elimination diets and fish oil supplementation seem to be the most promising dietary interventions for a reduction in ADHD symptoms in children. However, the studies on both treatments have shortcomings, and more thorough investigations will be necessary to decide whether they are recommendable as part of ADHD treatment.
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Affiliation(s)
- Maren Johanne Heilskov Rytter
- Maren Johanne Heilskov Rytter, M.D., Ph.D. student, Department of Nutrition, Exercise and Sports, Faculty of Sciences, University of Copenhagen , Frederiksberg , Denmark
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Janssen CI, Zerbi V, Mutsaers MP, de Jong BS, Wiesmann M, Arnoldussen IA, Geenen B, Heerschap A, Muskiet FA, Jouni ZE, van Tol EA, Gross G, Homberg JR, Berg BM, Kiliaan AJ. Impact of dietary n-3 polyunsaturated fatty acids on cognition, motor skills and hippocampal neurogenesis in developing C57BL/6J mice. J Nutr Biochem 2015; 26:24-35. [DOI: 10.1016/j.jnutbio.2014.08.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 07/01/2014] [Accepted: 08/05/2014] [Indexed: 01/08/2023]
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Bloch MH, Mulqueen J. Nutritional Supplements for the Treatment of Attention-Deficit Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2014; 23:883-97. [PMID: 25220092 PMCID: PMC4170184 DOI: 10.1016/j.chc.2014.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Polyunsaturated fatty acid supplementation appears to have modest benefit for improving ADHD symptoms. Melatonin appears to be effective in treating chronic insomnia in children with ADHD but appears to have minimal effects in reducing core ADHD symptoms. Many other natural supplements are widely used in the United States despite minimal evidence of efficacy and possible side effects. This review synthesizes and evaluates the scientific evidence regarding the potential efficacy and side effects of natural supplements and herbal remedies for ADHD. We provide clinicians with recommendations regarding their potential use and role in overall ADHD treatment.
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Affiliation(s)
- Michael H Bloch
- Yale Child Study Center, PO BOX 207900, 230 South Frontage Road, New Haven, CT 06520, USA.
| | - Jilian Mulqueen
- Yale Child Study Center, PO BOX 207900, 230 South Frontage Road, New Haven, CT 06520, USA
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Affiliation(s)
- Philip C. Calder
- Human Development and Health Academic Unit, Faculty of Medicine; University of Southampton; Southampton United Kingdom
- NIHR Southampton Biomedical Research Centre; University Hospital Southampton NHS Foundation Trust and University of Southampton; Southampton United Kingdom
- Department of Biological Sciences; Faculty of Science, King Abdulaziz University; Jeddah Saudi Arabia
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Pediatric Integrative Medicine Approaches to Attention Deficit Hyperactivity Disorder (ADHD). CHILDREN-BASEL 2014; 1:186-207. [PMID: 27417475 PMCID: PMC4928725 DOI: 10.3390/children1020186] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/22/2014] [Accepted: 08/15/2014] [Indexed: 12/20/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder in children and is increasing in prevalence. There has also been a related increase in prescribing stimulant medication despite some controversy whether ADHD medication makes a lasting difference in school performance or achievement. Families who are apprehensive about side effects and with concerns for efficacy of medication pursue integrative medicine as an alternative or adjunct to pharmacologic and cognitive behavioral treatment approaches. Integrative medicine incorporates evidence-based medicine, both conventional and complementary and alternative therapies, to deliver personalized care to the patient, emphasizing diet, nutrients, gut health, and environmental influences as a means to decrease symptoms associated with chronic disorders. Pediatric integrative medicine practitioners are increasing in number throughout the United States because of improvement in patient health outcomes. However, limited funding and poor research design interfere with generalizable treatment approaches utilizing integrative medicine. The use of research designs originally intended for drugs and procedures are not suitable for many integrative medicine approaches. This article serves to highlight integrative medicine approaches in use today for children with ADHD, including dietary therapies, nutritional supplements, environmental hygiene, and neurofeedback.
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Widenhorn-Müller K, Schwanda S, Scholz E, Spitzer M, Bode H. Effect of supplementation with long-chain ω-3 polyunsaturated fatty acids on behavior and cognition in children with attention deficit/hyperactivity disorder (ADHD): a randomized placebo-controlled intervention trial. Prostaglandins Leukot Essent Fatty Acids 2014; 91:49-60. [PMID: 24958525 DOI: 10.1016/j.plefa.2014.04.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 04/17/2014] [Accepted: 04/26/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine whether supplementation with the long-chain omega-3 polyunsaturated fatty acids eicosapentaenoic (EPA) and docosahexaenoic acid (DHA) affects behavioral symptoms and cognitive impairments in children 6-12 years of age diagnosed with attention-deficit/hyperactivity disorder (ADHD). STUDY DESIGN The randomized, double-blind placebo-controlled 16 weeks trial was conducted with 95 children diagnosed with ADHD according to DSM-IV criteria. Behavior was assessed by parents, teachers and investigators using standardized rating scales and questionnaires. Further outcome variables were working memory, speed of information processing and various measures of attention. For a subgroup of 81 participants, erythrocyte membrane fatty acid composition was analyzed before and after the intervention. RESULTS Supplementation with the omega-3 fatty acid mix increased EPA and DHA concentrations in erythrocyte membranes and improved working memory function, but had no effect on other cognitive measures and parent- and teacher-rated behavior in the study population. Improved working memory correlated significantly with increased EPA, DHA and decreased AA (arachidonic acid).
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Affiliation(s)
- Katharina Widenhorn-Müller
- Transfer Center for Neuroscience and Learning, University Hospital, Ulm, Germany; Department of Psychiatry, University Hospital, Ulm, Germany.
| | - Simone Schwanda
- SPZ, University Children׳s Hospital, Division of Social Pediatrics and Child Neurology, Ulm, Germany
| | - Elke Scholz
- Transfer Center for Neuroscience and Learning, University Hospital, Ulm, Germany
| | - Manfred Spitzer
- Transfer Center for Neuroscience and Learning, University Hospital, Ulm, Germany; Department of Psychiatry, University Hospital, Ulm, Germany
| | - Harald Bode
- SPZ, University Children׳s Hospital, Division of Social Pediatrics and Child Neurology, Ulm, Germany
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Puri BK, Martins JG. Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid validated meta-regression analysis of randomized controlled trials. Prostaglandins Leukot Essent Fatty Acids 2014; 90:179-89. [PMID: 24560325 DOI: 10.1016/j.plefa.2014.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 12/31/2013] [Accepted: 01/27/2014] [Indexed: 11/25/2022]
Abstract
Concerns about growth retardation and unknown effects on long-term brain development with stimulants have prompted interest in polyunsaturated fatty acid supplementation (PUFA) as an alternative treatment. However, randomized controlled trials (RCTs) and meta-analyses of PUFA supplementation in ADHD have shown marginal benefit, and uncertainty exists as to which, if any, PUFA might be effective in alleviating symptoms of ADHD. We conducted an updated meta-analysis of RCTs in ADHD together with multivariable meta-regression analyses using data on PUFA content obtained from independent fatty acid methyl ester analyses of each study PUFA regimen. The PubMed, Embase and PsycINFO databases were searched with no start date and up to 28th July 2013. Study inclusion criteria were: randomized design, placebo controlled, PUFA preparation as active intervention, reporting change scores on ADHD rating-scale measures. Rating-scale measures of inattention and hyperactive-impulsive symptoms were extracted, study authors were contacted to obtain missing data, studies not reporting negative findings had these data imputed, and study quality was assessed using the Jadad system plus other indicators. Random-effects models were used for pooled effects and for meta-regression analyses. Standardized mean differences (SMD) in inattention, hyperactive-impulsive and combined symptoms were assessed as rated by parents, teachers or all raters. The influence of study characteristics and PUFA regimen content was explored in multivariable meta-regression analyses. The overall pooled estimate from 18 studies showed that combined ADHD symptoms rated by all raters decreased with PUFA supplementation; SMD -0.192 (95% CI: -0.297, -0.086; P<0.001). However, when analyzed by rater, only parent-rated symptoms decreased significantly. Multivariable meta-regression showed that longer study duration, γ-linolenic acid (GLA), and the interaction between GLA and eicosapentaenoic acid (EPA) were associated with significant decreases in inattention; however, PUFA regimen content was unrelated to changes in hyperactive-impulsive symptoms. Certain fatty acids present in placebo preparations may potentially have been psychoactive. This meta-analysis provides modest evidence of PUFA effectiveness in ADHD, especially GLA and EPA for inattention symptoms; however, evidence of reporting bias, publication bias, variable methodological quality, and use of potentially psychoactive placebos limit the generalizability of these findings.
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Affiliation(s)
- Basant K Puri
- Department of Medicine and Department of Imaging, Hammersmith Hospital, Imperial College London, Du Cane Road, London W12 0HS, England, UK.
| | - Julian G Martins
- Academy of Nutritional Medicine, 80 Commercial End, Swaffham Bulbeck, Cambridge CB25 0NE, UK
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Stevenson J, Buitelaar J, Cortese S, Ferrin M, Konofal E, Lecendreux M, Simonoff E, Wong ICK, Sonuga-Barke E. Research review: the role of diet in the treatment of attention-deficit/hyperactivity disorder--an appraisal of the evidence on efficacy and recommendations on the design of future studies. J Child Psychol Psychiatry 2014; 55:416-27. [PMID: 24552603 DOI: 10.1111/jcpp.12215] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The efficacy of three dietary treatments for ADHD has been repeatedly tested in randomized controlled trials (RCTs). These interventions are restricted elimination diets (RED), artificial food colour elimination (AFCE) and supplementation with free fatty acids (SFFA). There have been three systematic reviews and associated meta-analyses of the RCTs for each of these treatments. SCOPE The aim of this review is to critically appraise the studies on the dietary treatments of ADHD, to compare the various meta-analyses of their efficacy that have been published and to identify where the design of such RCTs could be improved and where further investigations are needed. FINDINGS The meta-analyses differ in the inclusion and exclusion criteria applied to potentially eligible studies. The range of average effect sizes in standard deviation units is RED (0.29-1.2), AFCE (0.18-0.42) and SFFA (0.17-0.31). The methodology of many of the trials on which the meta-analyses are based is weak. CONCLUSIONS Nevertheless, there is evidence from well-conducted studies for a small effect of SFFA. Restricted elimination diets may be beneficial, but large-scale studies are needed on unselected children, using blind assessment and including assessment of long-term outcome. Artificial food colour elimination is a potentially valuable treatment but its effect size remains uncertain, as does the type of child for whom it is likely to be efficacious. There are additional dietary supplements that have been used with children with ADHD. A systematic search identified 11 RCTs that investigated the effects of these food supplements. Despite positive results for some individual trials, more studies are required before conclusions can be reached on the value in reducing ADHD symptoms of any of these additional supplements.
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Affiliation(s)
- Jim Stevenson
- Department of Psychology, Developmental Brain-Behaviour Laboratory, University of Southampton, Southampton, UK
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Dean AJ, Bor W, Adam K, Bowling FG, Bellgrove MA. A randomized, controlled, crossover trial of fish oil treatment for impulsive aggression in children and adolescents with disruptive behavior disorders. J Child Adolesc Psychopharmacol 2014; 24:140-8. [PMID: 24689967 DOI: 10.1089/cap.2013.0093] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Epidemiological research links aggression to low serum concentrations of omega-3 fatty acids, such as those found in fish oil. However, no studies have specifically examined whether fish oil supplementation can reduce the frequency and severity of impulsive aggression in children with disruptive behavior disorders. METHODS Children presenting with impulsive aggression and meeting research criteria for diagnosis of disruptive behavior disorders were randomized to receive either: 1) Fish oil capsules (4 g daily) for 6 weeks followed by placebo (identical-looking capsules) for 6 weeks; or 2) placebo for 6 weeks, followed by fish oil for 6 weeks, in a double-blind, crossover design. Primary outcomes were the Children's Aggression Scale and the Modified Overt Aggression Scale. Secondary outcomes included emotional and behavioral functioning (Strengths and Difficulties Questionnaire [SDQ]), hyperactivity symptoms (Attention-Deficit/Hyperactivity Disorder [ADHD] Rating Scale), family functioning (Family Assessment Device), and cognitive functioning (Stop Signal Task, Trail-Making Task, and Eriksen Flanker Task). Serum concentrations of omega-3 and omega-6 fatty acids were measured at baseline, and at 6 and 12 weeks. RESULTS Twenty-one children participated (81% male; mean age 10.3±2.2 years; range 7-14). Fish oil treatment increased serum concentrations of eicosapentanoic acid (F=14.76, p<0.05) and total omega-3s (F=20.56, p<0.05), but did not influence primary ratings of aggression. In fact, a trend suggested that fish oil worsened a secondary measure of aggression (SDQ Conduct Subscale, F=4.34, p=0.06). Fish oil treatment was associated with an improvement in one rating of hyperactivity (SDQ Hyperactivity Subscale, F=2.22, p<0.05), but did not influence any other outcome measures. CONCLUSIONS These findings suggest that fish oil treatment does not improve aggression in children with disruptive behavior disorders.
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Affiliation(s)
- Angela J Dean
- 1 Kids in Mind Research, Mater Research , Mater Health Services, South Brisbane, QLD, Australia
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