Lifestyle & diet
The benefits of regular exercise for general health are well known and in recent years the association between regular exercise and improved cognitive function has been reviewed in the literature.1-3
Although there is evidence to demonstrate the beneficial effect of physical exercise on symptoms of ADHD,4,5 these studies are limited by their size and further investigation will be required before these approaches are more widely addressed in clinical guidelines for the management of ADHD.
- In a study of children aged 8–15 years with ADHD (n=40), those who participated in a 30-minute period of moderate aerobic exercise performed better in various measures of executive function than those who did not4
- In an exploratory study of children aged 7–12 years with ADHD (n=21), those who participated in a 10-week high-intensity physical activity programme demonstrated improved muscular capacities, motor skills, level of information processing and behaviour reports by parents, compared with those who did not participate5
- In a study of children aged 8-10 years (n=40), a single 20-minute bout of exercise was associated with improvements in behavioural, neurocognitive, and scholastic performance in children with ADHD, although largely similar improvements were also observed in children without the disorder6
- In a pilot study of adults with ADHD (n=30; mean age 27.3 years), those who engaged in frequent aerobic physical activity had reduced behavioural impulsivity and less worrisome thoughts compared with those who engaged in non-frequent physical activity.7
Dietary interventions have been widely used in the treatment of ADHD; however, many of these diets are promoted without the support of scientific evidence, and currently none are recommended as part of ADHD management.8
In a large observational study (n=810), omega-3 and omega-6 fatty acids in combination with supplementary magnesium and zinc showed a beneficial effect on attentional, behavioural and emotional problems.9 In ADHD specifically, a meta-analysis of probably-blinded studies reported small but significant reductions in ADHD symptoms in association with free fatty acid supplementation, suggesting that this approach may warrant further investigation.10
In addition, there is preliminary hypothetical evidence from double-blind randomised studies that dietary supplementation with vitamins and minerals, but without omega fatty acids, may improve ADHD symptoms in adults,11 while daily phosphatidylserine may improve ADHD symptoms and auditory memory in children.12 It has also been hypothised that iron supplementation may be associated with improvements in ADHD symptoms in children, which may reflect observations that mean serum ferritin levels are lower in children with ADHD than controls.13,14
The elimination of artificial food colourings from the diet has been the subject of much debate in the literature.10,15 For example:
- A meta-analysis published in 2012, identified that while the effects of artificial food colourings on symptoms of ADHD were notable and warranted further investigation, they were susceptible to publication bias or were derived from small, non-generalisable samples15
- A meta-analysis published in 2013 that focused on probably-blinded studies found that elimination of artificial food colourings was significantly associated with reduction in ADHD symptoms; although they concluded that individuals in these studies were often pre-disposed to food sensitivities and that the clinical significance of the association between artificial food colourings and ADHD symptoms was yet to be determined.10
Given the public concern about a potential link between synthetic food supplements and hyperactivity, the FDA reviewed the scientific evidence available. They concluded that although a causal relationship between exposure to colour additives and hyperactivity had not been established in children in the general population. For certain susceptible children, conditions such as ADHD may be exacerbated by exposure to certain substances including, but not limited to, artificial food colourings.16
Evidence in support of physical exercise or dietary interventions for ADHD is limited and there is a lack of specific guidelines governing these approaches for patients with ADHD. Current recommendations, including the NICE guideline on diagnosis and management of ADHD in children, young people and adults, focus on the importance of regular exercise, a balanced diet and good nutrition for children, adolescents and adults with the disorder.17
- Ploughman M. Exercise is brain food: the effects of physical activity on cognitive function. Dev Neurorehabil 2008; 11: 236-240.
- Gapin JI, Labban JD, Etnier JL. The effects of physical activity on attention deficit hyperactivity disorder symptoms: the evidence. Prev Med 2011; 52 (Suppl 1): S70-S74.
- Ratey JJ, Loehr JE. The positive impact of physical activity on cognition during adulthood: a review of underlying mechanisms, evidence and recommendations. Rev Neurosci 2011; 22: 171-85.
- Chang YK, Liu S, Yu HH, et al. Effect of acute exercise on executive function in children with attention deficit hyperactivity disorder. Arch Clin Neuropsychol 2012; 27: 225-237.
- Verret C, Guay MC, Berthiaume C, et al. A physical activity program improves behavior and cognitive functions in children with ADHD: an exploratory study. J Atten Disord 2012; 16: 71-80.
- Pontifex MB, Saliba BJ, Raine LB, et al. Exercise improves behavioral, neurocognitive, and scholastic performance in children with attention-deficit/hyperactivity disorder. J Pediatr 2013; 162: 543-551.
- Abramovitch A, Goldzweig G, Schweiger A. Correlates of physical activity with intrusive thoughts, worry and impulsivity in adults with attention deficit/hyperactivity disorder: a cross-sectional pilot study. Isr J Psychiatry Relat Sci 2013; 50: 47-53.
- Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder – first upgrade. Eur Child Adolesc Psychiatry 2004; 13 (Suppl 1): I7-30.
- Huss M, Völp A, Stauss-Grabo M. Supplementation of polyunsaturated fatty acids, magnesium and zinc in children seeking medical advice for attention-deficit/hyperactivity problems - an observational cohort study. Lipids Health Dis 2010; 9: 105.
- Sonuga-Barke EJ, Brandeis D, Cortese S, et al. European ADHD Guidelines group. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 2013; 170: 275-289.
- Rucklidge JJ, Frampton CM, Gorman B, et al. Vitamin-mineral treatment of attention-deficit hyperactivity disorder in adults: double-blind randomised placebo-controlled trial. Br J Psychiatry 2014; 204: 306-315.
- Hirayama S, Terasawa K, Rabeler R, et al. The effect of phosphatidylserine administration on memory and symptoms of attention-deficit hyperactivity disorder: a randomised, double-blind, placebo-controlled clinical trial. Hum Nutr Diet 2014; 27 (Suppl 2): 284-291.
- Konofal E, Lecendreux M, Deron J, et al. Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol 2008; 38: 20-26.
- Konofal E, Lecendreux M, Arnulf I, et al. Iron deficiency in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med 2004; 158: 1113-1115.
- Nigg JT, Lewis K, Edinger T, et al. Meta-analysis of attention-deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. J Am Acad Child Adolesc Psychiatry 2012; 51: 86-97.
- Food and Drug Administration. Food Advisory Committee Meeting Materials March 2011. Background document for the Food Advisory Committee: certified color additives in food and possible association with attention deficit hyperactivity disorder in children. Available at http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/FoodAdvisoryCommittee/ucm149740.htm. Last accessed May 2015.
- NICE (2008) Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in Children, Young People and Adults. NICE clinical guideline 72. Available at www.nice.org.uk/CG72 [NICE guideline]. Last accessed May 2015.
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