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Fish Oil and ADHD: The New York Times Runs a Balanced Report
9/22/2008
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Experts point to the strong potential and need for more research; basic biology and some clinical studies offer hope

by Craig Weatherby



An article titled “Feeling Good About Fish Oil” appeared last week in The New York Times.

Several customers wrote to ask our opinion, so we decided to offer our take on the article. The report began with the story of a 4-year-old boy who began grinding his teeth at night and displaying obsessive behaviors to an “unnerving” degree.


Key Points

  • The New York Times reports that omega-3 fish oil shows promise in attention/behavior disorders.
  • Basic science supports the wisdom of trying fish oil in kids with ADHD, under a doctor’s supervision.
  • More clinical research is needed to test the efficiacy of fish oil; Safety is not in dispute.
  • Efficacy of fish oil may vary depending on the reasons for an individual child’s problems.

The boy’s pediatricianSandy Newmark, M.D., of Tucson, Arizonarecommended two supplements.


The first was inositol: a body chemical required for various nervous system functions, low levels of which are associated with depression and obsessive-compulsive disorders.


Dr. Newmark also recommended a daily teaspoon of fish oil, for its omega-3 fatty acids. (One teaspoon holds about 4,000 mg of fish oil.)


The Times article quoted the boy’s mother, Melissa Jump: “I saw a difference within a week. He’s more chill; he can roll with things more. He asks about his blanket every once in a while, but it’s no big deal.”

As Dr. Newmark says on his Web site, “…we recognize that there are times when stimulants such as Ritalin are necessary. Even in those cases, alternative ADHD approaches may support the child and minimize the dose of medication or side-effects.”


(Coincidentally, Vital Choice supports the Weil Foundation, which in turn supports the University of Arizona's Program in Integrative Medicine, where Dr. Newmark completed a two-year fellowship under program founder Andrew Weil, M.D.)


Signs of promise within a clouded picture

As Times reporter Roni Caryn Rabin wrote, “…many parents concerned about the side effects of conventional medications are turning to fish oil first, to treat not just mood disorders but also a variety of learning and developmental problems, including autism, dyslexia and, most notably, attention deficit hyperactivity disorder, or A.D.H.D.”


She spoke with Dr. Lawrence D. Rosen, who practices integrative medicine in Oradell, New Jersey, who told her that some children do well on fish oil and other nutritional supplements plus educational and behavioral aid, without medication.


But, as he told Ms. Rabin, “These are generally not the kids who have severe behavioral difficulties or incredible hyperactivity.”


Neither of the other two doctors interviewed expected that by itself, taking fish oil is likely to prove a consistently effective stand-alone treatment for ADHD, given individual variations in the condition's severity and possible causes.


But as every literature review finds, there’s promising (albeit mixed) clinical evidence, and plausible biological reasons why omega-3s in fish oil might help affected kids’ brains function better.


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

  • The full value of fish oil for ADHD and related conditions remains uncertain, due to a lack of reliable clinical evidence.
  • Fish oil is safe, and not known to exacerbate any ADHD-type disorders.
  • Fish oil enjoys fast-growing popularity among parents of children plagued by behavior and attention problems.

And recent scientific review papers on the subject agree that we need to know much more about the interactions between dietary omega-3s and genetic, nutritional, or environmental variables.


The small, weak, inconclusive body of clinical ADHD research on omega-3s is typical of nutrition-disease interaction research, almost all of which is designed and performed at universities to answer basic biology questions.

Generally speaking, only large pharmaceutical companies can afford the $200 million-plus process of proving the efficacy and safety of a proposed treatment to the FDA… whose approval is required to make and advertise enormously profitable disease-treatment claims.


Basic science supports an optimistic stance

Inclusion of Mayo clinical trial misleads

The Times article mentioned both of the above studies, but added that a four-month Mayo Clinic trial involving 63 children found no decrease in ADHD symptoms after four months of omega-3 DHA supplementation therapy (345 mg per day).


However, the Times article failed to note that, as the researchers wrote, the kids in the Mayo Clinic trial were “…all receiving effective maintenance therapy with stimulant medication.”


In other words, the children had been taking Ritalin-type drugs for some time, which had already reduced their symptoms substantially (Voigt RG et al. 2001).


Thus, the Times article leaves the impression that the Mayo Clinic trial was a meaningful test of the effects of omega-3s in ADHD. In fact, all the results showed was that omega-3 DHA did not reduce the kids’ symptoms further.


While this is nice to know, it’s not terribly surprising or helpful, nor does it mean that the supplemental DHA given the children did not improve mental functions that were not measured in the trial.

Of the two vital omega-3s in fish oilDHA and EPAthe one most closely associated with brain function is DHA.


In fact, DHA constitutes about 15 percent of the total weight of human brains (20 percent of infants’ brains), and about 60 percent of the brain’s cell membranes.


The DHA in cell membranes accounts for their unique fluidity.


And both omega-3s exert an astonishing range of influences, including regulation of neurotransmitters and gene transcription. They also serve as the precursors of the anti-inflammatory immune-system agent called autocoids, including some recently discovered compounds (neuroprotectins and resolvins) that may have particular importance to brain function.


In the developing brain, DHA stimulates nerve growth, and it accumulates preferentially in areas of high growth and activity (e.g., synaptic cell membranes, synaptic vesicles, astrocytes, myelin, and mitochondrial membranes).


And low levels of omega-3 DHA in children are linked strongly to increased risk of attention-deficit/hyperactivity problems.


Given its equally wide range of influences, there are good reasons to suspect that omega-3 EPA might positively influence attention deficit/hyperactivity tendencies in distinct ways as well.


Two recent studies support call for more research

Three years ago, we reported the results of a British clinical study that tested the effects of a supplement containing 80 percent fish oil in 117 children suffering from an attention-behavior disorder.


As the authors wrote, “Results showed… significant improvements in reading, spelling, and behavior for active treatment versus placebo during 3 months of treatment in parallel groups… [and] children continuing with active treatment maintained or improved their progress.”


(See “UK Study Finds Fish Oil Benefits Kids with Cognitive Defictits”. Note: The supplement used in this trial contained 20% evening primrose oil, which is high in an omega-6 fatty acid called GLA… see our sidebar titled “Why would an omega-6 help kids’ brains?”)


Last year, we summarized an Australian clinical trial that produced mixed results: surveyed parents reported positive changes in their kids, but teachers did not (See “Findings Support Omega-3s’ Ability to Aid Kids with Attention Disorders").


The evidence on fish oil and ADHD: Tantalizing but inconclusive

Why would an omega-6 fat help kids’ brains?

While American diets contain an unhealthful excess of omega-6 fatty acids, some children with attention disorders may need more of a specific omega-6 called arachidonic acid (AA) in their brain cells


Evening primrose oil holds therapeutic promise in attention disorders because it is rich in an omega-6 fatty acid called GLA, which serves as a precursor to AA.


Researchers hypothesize that a metabolic barrier in all or some children with attention disorders keeps their bodies from converting enough of the major omega-6 in people’s diets – linoleic acid (LA) from vegetable oils, meats, nuts, and seeds – into AA.


Omega-6 GLA is an intermediate step in the LA-to-AA conversion process, so the hope is that GLA-rich supplements can help bypass one metabolic roadblock to supplying ample AA to kids’ brain cell membranes.


Likewise, some researchers hypothesize that a metabolic dysfunction in all or some children with attention disorders keeps their bodies from converting enough of the (usually scant) amounts of plant-source omega-3s in their diets to DHA.

Alex Richardson, M.D., of Oxford University is a leading world researcher in the field of nutrition and diet.


She’s a leader of the famous, ongoing Oxford-Durham study, which has included some of the most rigorous trialsand encouraging resultsregarding the effects of omega-3s on child development. (See her biography and bibliography at Food and Behaviour Research, the UK charity she co-founded.)


Dr. Richardson has conducted several clinical trials testing omega-3s in child development and attention disorders, including one in which supplementation with omega-3s produced clear benefits in 41 children with ADHD: “…supplementation with [omega-3s] appears to reduce ADHD-related symptoms in children with specific learning difficulties” (Richardson AJ, Puri BK 2002).


It’s worth quoting these key points from Dr. Richardson’s clear-eyed review of the scientific literature (Richardson AJ 2006):

  • “Omega-3 fatty acids are dietary essentials, and are critical to brain development and function. Increasing evidence suggests that a relative lack of omega-3 may contribute to many psychiatric and neuro-developmental disorders.”
  • “Results from controlled treatment trials are mixed, but the few studies in this area have involved different populations and treatment formulations.”
  • “Dietary supplementation with fish oils (providing EPA and DHA) appears to alleviate ADHD-related symptoms in at least some children, and one study… also found benefits for academic achievement.”
  • “Larger trials are now needed to confirm these findings, and to establish the specificity and durability of any treatment effects as well as optimal formulations and dosages.”
  • “Omega-3 is not supported by current evidence as a primary treatment for ADHD or related conditions, but further research in this area is clearly warranted.”
  • “Given their relative safety and general health benefits, omega-3 fatty acids offer a promising complementary approach to standard treatments."

The Times article quoted Tufts University pediatric health expert Elizabeth Busch, M.D., who put her finger on the evidentiary problem in a recent literature review: 


“Because of the variety of subjects and inconsistencies in methodology, this growing literature lacks cohesiveness and is more tantalizing than persuasive” (Busch B 2007).


Since 2000, there have been seven published studies in children that looked at ADHD-related behavioral outcomes following fish oil treatment, and their deficiencies and inconsistencies make it impossible to draw clear conclusions:

  • Only four of the seven studies involved children formally diagnosed with ADHD.
  • The studies were conducted in five different countries with varied dietary patterns.
  • Few studies controlled for maternal smoking and/or alcohol consumptionboth of which can impair metabolism of omega-3s and omega-6sduring the children’s gestation.
  • Few studies recorded whether subjects were breast-/bottle-fed during infancy. (This oversight is important because, as we reported recently, maternal omega-3 intake during pregnancy and nursing appears to affect child development; see “Child Benefits of Fish Affirmed in Large Study”.).
  • No study considered the children’s overall omega-6/omega-3 intake ratio. (These two classes of fatty acid have very different effects, and compete for uptake into brain cells … an excess of dietary omega-6s can reduce the proportion of omega-3s in brain cells.)

And when the Canadian authors of a July 2005 reportfunded by the U.S. National Institutes of Healthexamined the available studies relating to pediatric ADHD, they could not come to any definitive conclusions concerning the value of omega-3s as a primary or adjunct treatment for ADHD (Schachter H et al. 2005)


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

We still know relatively little about the different effects of the two key omega-3s (EPA and DHA) and the varying effects of different blends of omega-3s and omega-6s.


These important questions remain unanswered:

  • Do the thinking, emotional, and behavior problems seen in ADHD and related conditions stem from deficiencies in certain children’s intake of omega-3s, or in their ability to metabolize dietary omega-3s?
  • Can all or some children diagnosed with ADHD benefit from taking fish oil, which is rich in omega-3s?
  • If some children can benefit from the omega-3s in fish oil, what doses and ratios of the key fish-derived omega-3s DHA and EPAare most effective?
  • Should some or all children with ADHD take selected omega-6s as well as omega-3 fish oil?
  • If some children can benefit from fish oil, how long would they need to take fish oil (or a combination of omega-3 and omega-6 fatty acids) before positive results begin to appear and reach their maximum level?

Sadly, only drug companies have the resources to run the several large-scale, long-term trials needed to settle these key questions… and, if warranted, gain FDA approval of fish oil as a treatment for ADHD or related disorders.


But because drug companies cannot patent omega-3s, they have little or no motive to spend the $200 million-plus it would take to gain FDA approval of fish oil as an ADHD drug.


What’s needed is a taxpayer-funded program to test natural products like omega-3s and vitamin D as treatments for, and/or preventive allies against, common diseases.


The NIH has long had a program to fund nutrition-disease studies at universities around the U.S., but it is not designed to answer the practical questions.


Americans should demand that Congress fund this urgent unmet need.


In the meantime, one thing seems certain: fish oil is safe, and unlikely to do harm.


So it makes sense for parents of affected children to discuss fish oil with their pediatrician as an initial or adjunct approach.



Sidebar


The Times mention of Mayo’s clinical trial misleads

The Times article mentioned both of the above studies, but added that a four-month Mayo Clinic trial involving 63 children found no decrease in ADHD symptoms after four months of omega-3 DHA supplementation therapy (345 mg per day).


However, the Times article failed to note that, as the researchers wrote, the kids in the Mayo Clinic trial were “…all receiving effective maintenance therapy with stimulant medication.”


In other words, the children had been taking Ritalin-type drugs for some time, which had already reduced their symptoms substantially (Voigt RG et al. 2001).


Thus, the Times article leaves the impression that the Mayo Clinic trial was a meaningful test of the effects of omega-3s in ADHD. In fact, all the results showed was that omega-3 DHA did not reduce the kids’ symptoms further.


While this is nice to know, it’s not terribly surprising or helpful, nor does it mean that the supplemental DHA given the children did not improve mental functions that were not measured in the trial.


END



Sources

  • Antalis CJ, Stevens LJ, Campbell M, Pazdro R, Ericson K, Burgess JR. Omega-3 fatty acid status in attention-deficit/hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2006 Oct-Nov;75(4-5):299-308. Epub 2006 Sep 8.
  • Burgess JR, Stevens L, Zhang W, Peck L. Long-chain polyunsaturated fatty acids in children with attention-deficit hyperactivity disorder. Am J Clin Nutr. 2000 Jan;71(1 Suppl):327S-30S. Review.
  • Busch B. Polyunsaturated fatty acid supplementation for ADHD? Fishy, fascinating, and far from clear. J Dev Behav Pediatr. 2007 Apr;28(2):139-44.
  • Frölich J, Döpfner M. [The treatment of Attention-Deficit/Hyperactivity Disorders with polyunsaturated fatty acids - an effective treatment alternative?] Z Kinder Jugendpsychiatr Psychother. 2008 Mar;36(2):109-16. Review. German.
  • Germano M, Meleleo D, Montorfano G, Adorni L, Negroni M, Berra B, Rizzo AM. Plasma, red blood cells phospholipids and clinical evaluation after long chain omega-3 supplementation in children with attention deficit hyperactivity disorder (ADHD). Nutr Neurosci. 2007 Feb-Apr;10(1-2):1-9.
  • Rabin RC. Feeling Good About Fish Oil. The New York Times. September 15, 2008. Accessed online September 15, 2008 at http://www.nytimes.com/2008/09/15/health/healthspecial2/15fishoil.html
  • Richardson AJ, Puri BK. A randomized double-blind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning difficulties. Prog Neuropsychopharmacol Biol Psychiatry. 2002 Feb;26(2):233-9.
  • Richardson AJ, Puri BK. The potential role of fatty acids in attention-deficit/hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2000 Jul-Aug;63(1-2):79-87. Review.
  • Richardson AJ. Omega-3 fatty acids in ADHD and related neurodevelopmental disorders. Int Rev Psychiatry. 2006 Apr;18(2):155-72. Review.
  • Schachter HM, Kourad K, Merali Z, Lumb A, Tran K, Miguelez M. Effects of omega-3 fatty acids on mental health.Evid Rep Technol Assess (Summ). 2005 Jul;(116):1-11. Review.
  • Sinn N, Bryan J. Effect of supplementation with polyunsaturated fatty acids and micronutrients on learning and behavior problems associated with child ADHD. J Dev Behav Pediatr. 2007 Apr;28(2):82-91.
  • Sinn N. Polyunsaturated fatty acid supplementation for ADHD symptoms: response to commentary. J Dev Behav Pediatr. 2007 Jun;28(3):262-3.
  • Voigt RG, Llorente AM, Jensen CL, Fraley JK, Berretta MC, Heird WC. A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder. J Pediatr. 2001 Aug;139(2):189-96.

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