30 | Sugar, Dyes and ADHD: Sifting Through the Science

6 million children living in the US have been diagnosed with ADHD. Many parents want to know if there is any treatment outside of medication and behavior therapy. As a provider, you may be wondering, "is there an ADHD diet I should put them on?" "Should they cut out all sugary foods?" This episode will give you the nutrition information you need to confidently guide your patients in their child's ADHD management. Joined by an expert in the pediatric neurodivergent space, Registered Dietitian Breta Alstrom is here to give us the science behind common misconceptions about diet and ADHD.

Key Takeaways:

1. Foundations of Nutrition: We explored the fundamental pillars of nutrition for ADHD kids—focusing on fat, fiber, and protein. 
2. Omega-3s : Discover the evidence supporting the inclusion of Omega-3s and explore creative ways to incorporate them into children's diets. From fish to flax and chia seeds, we've got super creative ideas.
3. Supplementation Strategies: Dive into the world of supplements, including multivitamins and the nuances of choosing the right options. Uncover the importance of personalized approaches based on individual needs.
4. Caloric Boosting Techniques: For underweight kiddos, we discussed strategies for adding calories without introducing entirely new foods. From fortified milk to Nutella banana roll-ups, find ways to make meals both nutritious and appealing.
5. Addressing Food Dyes: Delve into the debate around food dyes and their potential impact on behavior. 

Connect with Colleen on Instagram:
Exam Room Nutrition IG: ➡︎@examroomnutrition
Connect with Breta:
Instagram: @the.neuro.nutritionist
Online: https://www.nourishedtogether.com/

Transcript

Colleen: 0:00

Is there an ADHD diet? Does sugar make my kid more hyper? Should I eliminate food dyes? Adhd is one of the most common neurodevelopmental disorders of childhood, according to the CDC. This is using data from 2016 through 2019. The estimated number of children aged three to 17 years old diagnosed with ADHD is six million. Treatment includes medication and behavior therapy, but how often do you consider the impact of nutrition on your patient's symptoms?

Colleen: 0:34

My name is Colleen Sloan, I'm a registered dietitian and pediatric PA, and this is the Exam Room Nutrition Podcast where each week, I'm giving you the nutrition education you never got in school. I know many parents are wondering does nutrition play a role in ADHD management? After listening to today's episode, you will be able to confidently answer that question, in addition to learning strategies for helping kids with a low appetite, ensuring kids of all body sizes are meeting their micronutrient needs and the difference between micronutrients and macronutrients. And finally, we'll discuss exactly what the research says about food dyes. So get comfy and join me in welcoming my guest, breda Alstrom.

Colleen: 1:20

Breda is an award-winning dietitian who specializes in pediatric, integrative and functional medicine for neurodivergent children. Breda's career and education have been so unique and I'm so excited that she's here with us today. She received her master's degree from the University of Kansas Medical Center, focused on complex pediatric care and neurodevelopmental disabilities, reading her to become an advocate for the medical model that centers on accommodations for disability and family needs. You can follow her on Instagram at their neuro nutritionist, and I highly recommend you do. That's where we connected and her information is so helpful. This is why I'm super excited to have you on today, breda. Welcome to the show. Hi, thanks so much for having me. I can't wait to dive in. Yes, and this topic is huge. Whether you work in pediatrics or not, right? I mean, the statistics for ADHD are overwhelming and you either know somebody or work with someone who has ADHD, I'm sure. So this topic will be of interest to a lot of people. So I'm so curious about just laying the foundation of whether nutrition actually plays a role in the symptoms of ADHD.

Breta: 2:25

So long story short yes, it does, but I don't think it's always the same way that people think it is. So a lot of times people are seeking that perfect diet, like what diet helps with this, but really, when it comes to ADHD and pediatric nutrition at large, it's really about balancing the micronutrients and the macronutrients, and so I think with what we'll get into today is what that Nealtime composition looks like and what those nutrients that are supportive for improved attention and overall growth and development look like.

Colleen: 2:54

There are growing studies that talk about nutrition and ADHD and its impact on behavior. So I love having really smart dieticians on, because you give us the science and you clear up any of that junk that's out there and clear up all those nutrition myths. So let's dive into that first one that talks about sugar and ADHD. Is there really a link to increased hyperactivity?

Breta: 3:16

So no, the evidence does not show a link between sugar and ADHD. But if we look at overall behavior at large, that sugar and not really particularly sugar. But if we just look at the diets of what our kiddos with ADHD are consuming, it's a lot of carbs and that's going to cause those blood sugar spikes and those blood sugar crashes and that's going to lead to more behaviors. So what we want to really do is focus on getting in enough protein and fat with our carbohydrates so we can keep them balanced a little bit longer. We don't have as much of those spikes and crashes.

Breta: 3:51

And then there are some studies too that look at how are dopamine receptors functioning in kiddos with ADHD. So if we're looking at that dopamine response, it's not necessarily the sugar, but when we have sugar come into our body it does elicit a dopamine response. So then we're always kind of seeking the next thing and we want to have that heightened response. So if you feel like your kiddo has more sugar cravings, that might be why. But it doesn't cause ADHD, it doesn't have this profound impact on hyperactivity. But we do want to make sure that we have an overall healthy diet so that way we can have optimal development and manageable behaviors for both kiddos and parents, because nobody wants to feel like they're out of control after having a snack.

Colleen: 4:35

Exactly Super helpful. Now we will dive into what you had talked about, the difference between the macronutrients and micronutrients. But before we get into that, a very, very common concern that parents have and that children struggle with a lot with ADHD is a poor appetite as a side effect of their medication. So what are some strategies that clinicians who are listening can implement or suggest for their parents when they say my child's appetite just tanks in the morning or they don't want to eat any lunch, and we know that's a really common side effect of medication, how can we provide some support for that?

Breta: 5:09

Yeah, that's huge because that medication would be so helpful and so impactful for those kiddos. So one of the things that we can do is just make sure we have a really great meal time routine and structure. So for most kids it's going to be three meals and three snacks a day, with two to three hours in between, and if a child has a really low appetite, we might cut one of those snacks to try and help improve the appetite at the next meal. And then, by having those regular offerings, that will hopefully prime them to eat a little bit more. That is not always the most effective. So a couple of other things that we can work on would be making sure that they get a good amount of protein when they are eating. That way they have all those nutrients that they need. And then we can also leverage oral nutrition supplements so commonly like pediacure, but there's plenty of other options out there as well.

Breta: 5:54

And then if you are a clinician something that has been really helpful for my kiddos if you're a prescribing physician is sometimes an appetite stimulant can be the most helpful thing in being able to, you know, start eating a little bit more, start working on diet variety, and then we can reap the benefits of that later on.

Breta: 6:12

It doesn't have to be a forever thing, and then I always like to focus on strength based support. So, outside of medication, sometimes with the attention issue, we just have trouble at meal times. It can be really hard. So sometimes sitting for a whole 15, 20 minutes isn't going to be a great option, and that's something that we can work on over time. But having opportunities to get up during the meal to take a little break and come back and then eat a couple more bites, or if there's something we can do for better engagement at the table, maybe we have something that we can color on in between bites, but something to keep us engaged, something to keep us at the table Even if you're not eating or you're not hungry due to those medications. Staying at the table and working on those behaviors is going to be really critical.

Colleen: 6:53

Oh, I love that. I'm going to start recommending that they have like a little coloring sheet at the table, because that's a great, great suggestion to keep them engaged. So I love that. Now we'll stick with the kiddo that's maybe got a poor appetite and now they are underweight. So this is also a really, really challenging kiddo to see in clinic Again, because we're rushed, we don't have a lot of time, but this is very important. So what are some strategies or foods or suggestions that we can provide to the parent when the child is either floating at the fifth percentile or even dipping down below on their growth chart and they're underweight due to this poor appetite or just really because they're having some difficulties with meal times?

Breta: 7:33

This is a really great time to leverage those oral nutrition supplements if we can get all of those micronutrients in, which is critical. A lot of times we just focus on the macronutrients, we focus on the growth and like, oh you know we're inching up, but are we really well nourished? And that's a whole other question. So an oral nutrition supplement like PDSR can be really helpful. If you have a kiddo that is actually looking there, may be more interested in like the juicy kind of flavors and things like that you can look for like an inch or clear or a boost freeze, like. We want to play into their strengths and what's going to work the best for them. They do have a little bit of different micro and macronutrient compositions, so we do want to be mindful about what their actual needs are. But that's the number one most helpful thing for getting them to progress on that growth chart. But we also want to make sure that we're leaning back into those, like that, foundations of feeding. So our male time behaviors do we have those two to three hours in between and the nice thing about a lot of this is it overlaps and it double dips. You don't need to have a separate recommendation for every single thing. We just need to really set a good foundation, and if we're struggling with that, then our referral is really helpful.

Breta: 8:34

And then, on top of all of that, it's the fats. The fat has, you know, nine calories per gram compared to our protein and our carbs. So if we can help increase the fats that our kids are getting, which is also going to help them with that attention and some of those behaviors too and keeping our mood stable, that is going to be really helpful. So if your child, or the child that you're seeing, tolerates dairy really well, often a full fat dairy is the easiest option for most kids. If you can find a full fat yogurt, cream cheese, and then, if we're looking more on like the veggie side of things, we can get some avocado in. And all of this rate is based on how selective they are with their food choices, but really aiming for those high fat foods. And then nut butters can also be something really simple to leverage, and dips and sauces and dressings that are a little bit higher in fat.

Colleen: 9:21

Yes, fat is always my go to as well, too, when we're trying to add on a little bit of weight to those children, because it's an easy thing too to kind of sneak in to the diet. Like, if they don't like avocado but they like a smoothie, you can easily put a tablespoon of avocado in a smoothie and it blends right in and they don't even taste it. So it's a really good way to fortify the foods that they're already eating. Now we're finally to where I know a lot of my listeners want to get to, and that's really like the diet. Before we talk about, is there an ADHD diet, because that's kind of the buzzword around. You have mentioned these two words so often, and I want to make sure that we clear it up for our listeners the difference between macronutrients and micronutrients. How do they play a role in the diet? What are they kind of? Give us the nutrition 101 for those of us who don't even know what you're talking about when you say those two words.

Breta: 10:11

Yeah. So our macronutrients are going to be our protein, our carbs and our fat. And how I like to break it down is protein what? What's it going to do for us? So protein is going to help balance mood, it's going to promote fullness, it's going to support all these metabolic reactions that we need to have happen in our body for optimal functioning. And then our carbs.

Breta: 10:30

Now, kids need carbs, even though we talked about those blood sugar spikes and crashes. We just need to have balanced meals. We don't want to cut any of the carbs out for them. It's a really good energy source. It's super critical for their growth and development, but they're going to be a quick energy source and it's that preferred energy source of the brain, so it does help.

Breta: 10:47

So sometimes, you know, you might see a little bit of that extra stimulus, and this like does vary too by comorbidities that a child might have as well. So a lot of developmental delays are compounded by other developmental delays. So if a child also has, like, high tone or low tone, like those are things that require additional nutrition interventions that tweak our recommendations and the amount of macronutrients that we're recommending too. And then, when it comes to fat, we are going to use the fat to help balance mood, promote fullness, and it's going to be that long acting energy source so we don't have those crashes, so we can get from meal one to meal two. And if we're going to drop that snack to help improve appetite, it's going to help keep us stable longer during those times.

Breta: 11:28

And all those macronutrients are the building blocks of development. So we want to make sure that we're including those. And then, when it comes to micronutrients, those are going to be our vitamins and minerals. They all play different roles in the body but they feel those metabolic reactions. They act as like the spark plug to our metabolism. So those are really critical and there's a lot of different micronutrients that are going to play a role in ADHD make sure you're getting in your macros is sort of like the buzzword of an adult diet.

Colleen: 11:54

Right now. Everybody's talking about macros and it kind of gets annoying. But in kids it's just what our diet is made up of. It's just the basic carbs, protein and fat. So thank you so much for clarifying that. So is there an ADHD diet? Is there a specific diet that we as clinicians should say here follow this, eat this, and your child's behavior will be so much better.

Breta: 12:16

So, no, there is a little bit of research coming out about the Mediterranean diet, but getting kids to eat anything sometimes can be a huge challenge. So instead of focusing on like what's the perfect diet, I like to focus on what can we add to their diet. And so about half of kids with ADHD have a really suboptimal diet compared to like 10% of typically developing kiddos. So it is like a really big issue. But if we can look at, okay, well, they eat toast and that's all they want to eat, well, great, can we add butter to our toast? Can we add a peanut butter to our toast? What can we put with that to make it meet their needs a little bit better? So instead of eliminating a bunch of things, which I think people are really quick to do, if we can focus first on what can we add to their diet to really help support that development and those behaviors, that's the easiest place to start and the best thing to do.

Breta: 13:05

There's also really good evidence to want to including omega threes. So if you're doing that from diet, that's going to be. You know our fish as well. Again, depending on the kiddo, some kids are really good eaters. Some kids are not. Fish may or may not be an easy sell.

Breta: 13:19

You can also look for some plant based on omega threes. Now, they don't convert as well into that APA and DHA, but flax seeds and chia seeds are also really good tools that include fat and fiber, and they can help with other things like constipation too. So those are the things that we want to look for, in addition to making sure that we have fat, fiber and then protein. And if your child doesn't like meats, or the child that you're seeing doesn't like meats, we can look for some of those alternatives that we can offer, like so maybe some plant based options, maybe beans, nuts and seeds and things like that, on ways we can start to boost their protein, because kids really don't have a super high protein need. Or even looking at some functional foods, like is there a bar they could have that has, you know, four to five grams of protein in it and that would meet their needs for that meal? And then we can start building on that. Once we have those building blocks there, we can start building on diet variety.

Colleen: 14:10

Awesome, you mentioned chia seeds and flax seeds. So if this is totally new to clinicians or to parents, how do we incorporate that into the diet? Like, do they just take a spoonful and knock it back? Or how do you suggest that we say okay, maybe you can offer some chia seeds or flax seeds, but how?

Breta: 14:28

So a simple way. And again, it really depends on texture preferences for the child. But you can add these things to yogurt super simply. For older kids who are a little less selective, I'll actually just have them mix chia seeds in the water, let it sit there for a little bit. If juice is something they can have a small amount of, just based on their nutrition needs, they can mix it in your juice and it makes it a little bit more palatable. And then I always recommend to for kids doing the white chia seeds instead of the black chia seeds, just because it's that is visually disrupting for them. And then you can also mix it into smoothies. You can make chia seed pudding with a little bit of whole milk and some fruit and put that in the fridge. I do think flax ground flax is a little easier to incorporate, and you can find ground chia at the store, which is also super simple to incorporate. But if you try to grind chia at home it turns into like a weird jelly sludge. So just something to keep in mind.

Colleen: 15:22

That's awesome, super helpful. All right, we've mentioned supplementation, so like with the PDE, assure and other brands that are out there just to get some extra calories into their little bodies. But what about vitamin supplementation? Is this a routine thing that we should suggest every you know selective ADHD kiddo should be on a multivitamin or is this a case by case?

Breta: 15:44

recommendation A multivitamin is a really great place to start. If we have low appetite, if we have just a low variety of foods, a multivitamin can be really helpful. The biggest problem with multis is the most complete multivitamins are going to be those hard chewables. It's a lot harder to get a lot of these kids to take a hard chewable multivitamin. So then if we look at gummies, it's really about which gummies have the most, and I don't think there's a particular go-to brand for this. I would refer to a dietitian to go through it, like one by one. I've got my DRI calculator where I look at all the nutrients and how we're stacking up, and maybe we need two if we don't eat any food, because for some of these kids it might actually be a little bit less supplemental and it might be a little bit more of that core nutrition. So it really does depend on exactly what they need. But outside of a multivitamin which, when we think about multivitamins too, this can be really critical for kids that might actually end up having a higher weight we think a lot about nutrition for kids that have a lower weight, but for kids that have a higher weight, I have a lot of kids that still don't eat anything and so it's harder to get them the support and resources they need for actual nutrition because they're like, oh, they're growing okay, but just because they're growing okay doesn't mean they're well nourished. So often, looking at even if that's a reduced calorie, a pediatric or a different option, that can be really helpful for making sure they have all the building blocks and keeping those mood stable. And then a multivitamin can be a super simple solution for a child with a higher weight to make sure they're meeting their micronutrient needs.

Breta: 17:17

If you're looking at things a little bit extra for kids, that won't necessarily be harmful. You can look at Omega-3s. That's a really easy addition. You're talking about getting those from fish and things in it. That's a little more challenging. Getting an extra Omega-3s is great for brain development, hpa access regulation, so like anxiety and depression and how we're managing our mood, those things are all really well documented.

Breta: 17:40

When there is a little bit of evidence on magnesium and B6, the problem is, if you give too much magnesium, we end up with some of those GI symptoms. So I don't recommend parents do a lot of supplementation on their own. I do think they should work really closely with someone. Same thing with zinc. Zinc can be really helpful, but a lot of times even adults take zinc in way too high of quantities, pretty chronically. So that's something that they should definitely work with a clinician on if they've done a bunch of research and they're wanting to supplement and do this and that I would definitely make a referral so we can make sure that we can stay aligned with the family's values but also make sure that we're keeping their kiddo safe.

Colleen: 18:16

I love that you mentioned that just because a child is at normal weight or maybe even on the overweight side of their growth chart, they might not be well nourished because the growth chart and the weight, the number on the scale, is not the end all be all, because they could be growing fine and weigh a normal weight and only be feeding themselves with chicken, nuggets and mac and cheese. It's not a well balanced diet and they're likely not meeting those micro nutrient needs. So I'm really glad that you mentioned that. So as clinicians, it's super important that we do ask about what foods that the child typically eats. Is there a phrase or a way that you like to word that question? Because when we ask kids what does your diet look like, it kind of is funny because they're like well, I'm not on a diet. So are there certain ways that you like to ask what does your diet look like?

Breta: 19:04

to kids. Yeah, so, depending on how old the child is, sometimes I just ask them what their favorite food is, and then I'll go through like each of the food groups, like do you have a favorite fruit, do you have a favorite vegetable? And sometimes, like their parent will help them with some of those questions, and then other times it's parents. They just have concerns, so like they only eat like X, y and Z, and this is a problem. And then also I'll just ask people like oh, what did you have for breakfast? So instead of asking them what your variety is, I'll just go through a quick diet recall on, like what's a normal breakfast for you? What are your normal snacks? What's a normal lunch? Are you eating at school? Things like that.

Colleen: 19:38

Yeah, that's super helpful and I think that's important to know because then you get an idea of if they have a decent variety or if not. So, lastly, I wanted to close with asking a question that's pretty common out there and again I'm sure there's some debatable research and that's regarding food dyes and if this has an impact. Do you know the science behind this and if we should be recommending that you know kiddos avoid those food dyes, or if it's okay if they have some of those foods?

Breta: 20:05

So it really depends on the child. I think every child ends up tolerating dyes a little bit differently. Now the trouble with this is the evidence and the research right. So no-transcript. The FDA has not really studied the effects of food dyes on behavior, but it is pretty well documented in the UK. And then there's some things that they've removed and so I know a lot of people think about just red dye, but it could be blue, yellow or green and some symptoms you might see could be sleep disturbances, behavioral problems, hyperactivity, and it could aggravate additional health problems for kids that are sensitive to this.

Breta: 20:38

So it really depends, though I just personally don't see any harm in removing food dyes generally and you can try it and see if it helps and if you notice benefits, great. If not, no need to restrict. But most of the foods that have food dyes in them aren't going to be a core food group for you and there's a lot of substitutions, like one thing that we do a lot when we do feeding therapy with kiddos is like fairy bread, which involves like putting sprinkles on you know, cream cheese on a slice of bread and stuff. But we can find dye-free sprinkles and there's most of the things out there that you would want to eat, that you can find dye-free to. But again, the research I think could still use a little bit of additional evidence here in the US.

Colleen: 21:17

So helpful. Thank you so much for merging science and medicine and nutrition, because it's so helpful, so I'm so grateful that you were here with us today.

Breta: 21:25

Is there anything that we didn't cover on this flyover ABHD and nutrition topic today, that you would like to leave our clinicians with the only additional thing would be, you know, when we're making nutrition supports and creating solutions that they just really play to the child's strengths which I know, if you're in like a 20 minute visit with someone, you don't really have the time to do that. But that could be a referral to a dietitian, it could be a referral to an SLP, an OT or someone who does have the time to spend a little bit more time with them to help them meet their needs.

Colleen: 21:51

Brett, thank you so much for being here. I'm so grateful for your time and we would love to have you back on again. So thanks again for being here with us.

Breta: 21:59

Thank you so much for having me.

Colleen: 22:01

All right, guys. Now it's time for my nutrition notes. In this section, I will leave you with a nutrition tip and encouraging quote or an interesting case that I think might add value to your day. So today I want to leave you with a nutrition tip. Brett and I discussed some nutrition techniques to add some calories to our underweight kiddos, or those kiddos who are struggling with their appetite, and you are trying to boost up their calories. So I wanted to leave you with a few things that you can suggest your parents do, and the way I like to explain this is that we aren't necessarily going to make them eat any new or different foods, because that can already be very challenging for our kids, but we work with what they already do eat and try to find ways that we can fortify it. So the best example of this is using milk, just so parents can understand what I mean by fortifying their food. So, for example, if your family or your child is eating 2%, 1% or fat free milk 8 ounces of that now we should recommend that they switch to whole milk, because they're still going to eat 8 ounces of whole milk, but that whole milk gives them a little bit more bang for their buck, meaning they're getting more calories in the same amount of food that they're eating. So milk is a great way that you can do that. So opt for whole fat, whole milk, cheese or yogurts. Brett had mentioned that avocado is a really great fat source that we can be including into their diet and, like I said, you can mix a tablespoon into a smoothie and that becomes undetected. Sometimes kids actually do like avocado, so you could try it out. You can make them avocado toast. Put some fun sprinkles on it. You could even use flaxseed as a sprinkle topping, just to add a little bit more fat and fiber. You can use guacamole as a dip. Kids love to dip foods, so if they like guacamole, or even just the plain smashed up avocado, they can dip it with crackers, carrots, celery whatever food they like. They can dip that in as well.

Colleen: 23:52

For our super selective eaters who are not of interest at all and unwilling to try any new foods, that's when I recommend that parents fortify the foods that they're already eating. So, for example, if your child already loves noodles or they already love rice, then you can add a little fat to it by drizzling it with some cooking oil like olive oil or coconut oil or even just a little bit of melted butter. And if they drizzle a little bit like a teaspoon or tablespoon into their foods that they're already eating and they do that at every meal it doesn't change the flavor, but it adds a little bit of extra fat for them as well. Now some fun foods that I like to recommend.

Colleen: 24:27

Parents try out our Nutella sandwiches. Nutella is a really delicious chocolatey hazelnut spread that a lot of kids really like. Another thing you can do with Nutella is make Nutella banana rollups. You can do this with a flour tortilla, spread a little bit of Nutella and thinly slice some bananas and you can just roll it up and make like a little sandwich. It's kind of similar to like a Nutella banana crepe. It's a delicious snack. It's a really good thing that you can offer to them as dessert or even just a meal as well If they love peanut butter and jelly sandwiches.

Colleen: 24:58

You can actually make a triple decker peanut butter and jelly sandwich, spreading peanut butter jelly like a normal sandwich, but you're just using an extra third piece of bread on the top and making like another peanut butter and jelly section. So you've got a tower of three slices of bread. You could squish it down too, so that they don't really know that they're eating that much more, but it's a quick and easy way to add some calories. So I hope you found those tips helpful and that you might be able to suggest some of those ideas to some of your parents struggling with getting their child to gain a little bit of weight. Well, that's all for today, guys. Thank you so much for joining me. If you'd like to connect with me, you can find me on Instagram at exam room nutrition. Well, as always, let's continue to make our patients healthier when exam room at a time. I'll see you next time.