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Nutritional Supplements in ADHD by James Greenblatt, M.D.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 38:10, OCTOBER 1999
I read with great interest Dr. Heimann’s letter (1999) on pycnogenol in the treatment of attention-deficit hyperactivity disorder (ADHD). I have treated more than one hundred patients with ADHD, using nutritional supplements similar to pycnogenol (pine bark extract). His letter prompted me to share my experiences with your readers; I hope this letter will further discussion.
The biologically active compounds found in pycnogenol are oligomeric proanthacyanidins (OPCs). The use of OPCs for the treatment of ADHD has been circulating among parent groups, multilevel marketing companies, and Internet groups for at least 6 years. I became interested in these compounds after a treatment resistant patient showed significant improvement without medications. Over the past 4 years I have recorded case studies demonstrating (1) EEG changes, (2) handwriting improvement, (3) improved school performance and (4) continuous performance testing improvements. Family reports have ranged from no change to dramatic changes. There are few side effects of OPCs, although some children become irritable and have decreased energy. I have found the most significant improvement noted by patients are in areas relating to sustained attention and distractibility, rather than hyperactivity and impulsivity.
OPCs are one class of Flavanoids. Flavanoids are a ubiquitous group of polyphenolic substances which are present in most plants. OPCs have been isolated from many plants including apples, berries, grapes, raspberries and blackberries, and are also present in many red wines (Schwitters and Masquelier, 1995). Although OPCs were originally extracted from pine bark, pine bark (pycnogenol) is significantly more costly than extracts from other plant materials. In my practice I have found that patients taking grape seed extract or OPCs from many different sources have more consistent responses.
How OPCs improve brain function and possibly symptoms of ADHD is speculative. The simplest explanation may involve the protective effects of proanthocyanidins on brain lipid peroxidation. There are animal models that have demonstrated this effect with grape seed extracts (Bagchi et al., 1998). Free radicals have been implicated in a number of disease processes including asthma, cancer, cardiovascular diseases, cataracts, diabetes, macular degeneration, Parkinson disease, and many other inflammatory processes. The brain may be particularly vulnerable to free radical damage because neurons are so rich in docosahexaenoic acid (DHA), a highly polyunsaturated fat. Unfortunately, as Dr. Heimann pointed out in his letter, there are not any published studies of ADHD and OPC, either alone or combined with other treatment strategies.
There is a rapidly expanding body of literature on nutrition and brain function. The research is embedded in non-clinical journals and headlines are quickly picked up by the unregulated health food industry. Hence, the “miracle cure” of the week is discovered. Nutritional claims in the treatment of ADHD have a long history of parents and professionals taking sides. Diet fads and “alternative” therapies come and go as parents desperately seek help. Nutritional biochemistry and the understanding of cellular metabolism is not alternative medicine, but the foundation for health and all disease processes. Medicine has slowly embraced nutritional research. Psychiatry has lagged far behind. The benefits of nutritional supplementation have quietly penetrated such conservative medical publications as the New England Journal of Medicine (Oakley, 1998).
Diet has been associated with many major chronic illnesses. The research is quite clear that lifestyle choices including dietary habits affect our genetic potential. Many of my colleagues dismiss the role of nutrition in ADHD, quoting old negative studies on food additives, sugar, and megavitamin therapy. A 1997 study published in Pediatrics found only 1% of children and adolescents met recommended dietary allowances, with 50% of daily calories from fat and sugar (Munoz et al., 1997). A study published in this Journal found that food insufficiency and hunger are associated with poor behavioral and academic functioning (Murphy et al., 1998). Is it such a leap of scientific faith to surmise that the incredibly complex neurochemistry that controls our ability to pay attention may need a sufficient supply of nutrients for optimal functioning?
ADHD is a complex, multifaceted disorder that disrupts psychosocial development and may have profound consequences in every aspect of a child’s life. Understanding ADHD as a genetic neurobiological disorder or “chemical imbalance” might provide an explanation for parents giving their children psychotropic medications, but it does not explain the tremendous variability of symptoms, nor the treatment success many of us have had with OPCs and other nutritional interventions.
In my psychopharmacology practice, I have had clinical success in treating children and adults with ADHD utilizing OPC, adjusting protein-carbohydrate ratios, and supplementing with trace minerals and specific fatty acids based on a detailed red blood cell membrane analysis from Kennedy Krieger Institute in Baltimore. OPCs are safe, naturally occurring, nontoxic compounds that might cost families a few cents a day. Clinical trials are desperately needed to begin a scientific understanding of these exciting case studies. I hope that funding can be found for an unpatentable compound that might not provide a significant income for a pharmaceutical company, but might provide an effective biological alternative for many patients.
James Greenblatt, M.D.
Comprehensive Psychiatric Resources, Inc. Newton, MA
- Schwitters B, and Masquelier J. OPC in Practice: The Hidden Story of Proanthocyanidins, Nature’s most powerful and patented antioxidant. Rome, Italy: Alpfa Omega Editrice 1995.
- Bagchi D, Garg A, Krohn RL, Bagchi M, Bagchi DJ, Balmoori, and Stohs, SJ. Protective effects of grape seed proanthocyanidins and selected antioxidants against TPA-induced hepatic and brain lipid peroxidation and DNA fragmentation, and peritoneal macrophage activation in mice. Gen Pharmacol 1998,30(5):771-6.
- Oakley, GP. Aging Better. N Engl J Med. 1998;338(15)1061-4.
- Munoz K, Krebs-Smith S, Ballard-Barbash R, Cleveland L. Food intakes of US children and adolescents compared with recommendations. Pediatrics 1997;100:323-9.
- Murphy JM, Wehler C, Pagano M, Little M, Kleinman R, Jellinek M. Relationship Between Hunger and Psychosocial Functioning in Low-Income American Children. J Am Acad Child Adolesc. Psychiatry 1998; 37(2):163-170.
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