Behavioral Effects of a Modified Mediterranean Diet on Children with ADHD (MedDi)
Diet: A Stepping Stone along the Path to Self-Regulation
At this point in our evolution, VRF is interested in conducting studies that have a high probability of making an inroad into the reduction of violence in our society. We are now investigating a non-pharmaceutical intervention for children with ADHD in the form of the Mediterranean Diet that: (1) contains foods rich in essential nutrients; (2) discourages consumption of foods with few essential nutrients’ and (3) neither prohibits nor mandates any particular food items. In this regard, the Mediterranean Diet is not a rigid diet, but rather a set of eating practices traditionally found among people in countries that border the Mediterranean Sea:
- High consumption of fruits, vegetables, whole grains, and legumes
- Moderate consumption of fish and seafood
- Olive oil as the main source of dietary fat
- Reduced intake of refined carbohydrates and saturated fats
The Mediterranean Diet is thought to provide higher levels of nutrients that support optimal brain functioning, including maintenance of attention, working memory, impulse control, and mental flexibility.
In 1973 pediatrician Benjamin Feingold wrote that foods commonly found in children’s diets were largely responsible for the symptoms of ADHD. At about the same time, Nobel Laureate Linus Pauling was advocating for the treatment of behavior disorders by “the correction of innate or acquired chemical imbalances using amino acids, vitamins, minerals and other biochemicals.” Since then, reviews of controlled research studies on the “Feingold diet” have shown that elimination of various foods (e.g., sugar) has no lasting effect on ADHD symptoms. On the other hand, recent studies by the U.S. Department of Agriculture still report that more than 30% of all American children fail to meet minimum requirements for fruit and vegetable intake, and over 50% could be considered clinically malnourished.
While nutritional deficiencies are probably not sufficient in themselves to cause ADHD-like symptoms, these deficiencies may lower the threshold for inattentive and impulsive behavior, as has now been demonstrated in more than a dozen well- controlled studies of nutritional supplementation with vitamins, minerals and polyunsaturated fatty acids. Nevertheless, compliance remains a problem for children taking vitamin-mineral supplements, and parents become discouraged as behavioral changes associated with dietary supplements are neither sudden nor dramatic.
Clearly, the Mediterranean Diet has a great deal to recommend it, in terms of ameliorating the disorders of attention and emotional regulation that are found in conditions such as ADHD, a disorder that has been found to be associated with conduct problems that may often culminate in interpersonal violence. The primary end point of the study will be to reduce the specific symptoms of ADHD by systematically implementing MedDi in participating families.
- Enable change through empowerment
- Reduce impairment
- Increase adaptability
- Create & disseminate a repeatable model
Subjects. We will recruit up to 60 children, ages 9 through 12, all of whom will have been previously diagnosed with ADHD, using the criteria established in the Diagnostic and Statistical Manual of the American Psychiatric Association, 5th Edition (DSM-5). We obtain legal informed consent from the families of no fewer than 48 children. We will then randomly assign the 48 subjects to two study groups: Group 1 (24 subjects) will receive a Social Skills Training Program (SSTP) for six weeks, followed by MedDi Program for 24 weeks, followed by crossover to passive observation for 24 weeks. Group 2 (24 subjects) will receive SSTP for six weeks, followed by passive observation for 24 weeks, followed by crossover to MedDi Program for 24 weeks. Thus, children in both groups will be participating in the active treatment (MedDi) condition, but Group 2 will be delayed by 24 weeks. This is a standard “waiting group” design.
Assessment. Over the course of the study, subjects will be assessed at several points in time, using the following instruments:
- Health and fitness battery
- Laboratory tests of attention, learning and memory
- Behavior rating scales (parent/teacher ratings)
- KIDMED dietary assessment (via parental interview). Note: During the initial evaluations of subjects, KIDMED will be administered via interview with a trained examiner, who will instruct the parent so as to lend uniformity to the later (monthly) parental KIDMED ratings over the course of the study.
Intervention. In the Med Di condition, which will last approximately 24 weeks, parent(s) and child will attend an initial two-hour nutrition lecture, during which materials describing MedDi will be provided. On a monthly basis, the parents and child will attend a combination nutritional lecture, cooking demonstration, and dinner served by Master Chef Massimo Navaretta in the conference room of his restaurant, Onotria (six monthly sessions in all). During these sessions, Chef Navaretta will lecture on the benefits of dietary practices commonly referred to as the “Mediterranean diet,” especially as found in the rural, mountainous regions of Central Italy. Each lecture will emphasize a particular component to the diet, contrasting the nutritional values of “Mediterranean” with “Western” approaches. The lecture will be combined with a demonstration of simple methods of preparing a meal representative of the day’s lecture. Following the cooking demonstration, the family will be served with this same meal.
The lectures/cooking demonstrations will be video recorded, and DVDs of the lectures will be made available to participating families shortly following each session. We have also arranged with local public television to videotape the Navaretta lectures and cooking demonstrations in preparation for a release of the series over public television.
Analysis of Results
In analyzing the results we will be taking advantage of major advances in the statistical methods available for the quantitative analysis of longitudinal data. These methods will enable us to answer the following questions:
- What happens over time?
- Is the outcome attributable to a) social skills training, b) MedDi, or c) both a and b?
- Is growth in social skills acquisition (growth) linear, or are there plateaus?
- Where does the process start?
- How rapidly does the process develop?
- Is there a steeper slope of skill acquisition at some point (e.g., after several weeks of MedDi)?
- What accounts for the rate of growth?
- Does the rate of change in one attribute relate to the rate of change in another?
Based on the above considerations, an optimally approach to nutritional intervention for Children with ADHD would seem to one that:
- Encourages consumption of foods that are rich in essential nutrients
- Discourages consumption of foods that have relatively fewer essential nutrients
- Neither prohibits nor mandates any particular food item
- Neither guarantees nor implies that ADHD-like symptoms will be mitigated in the short run with adherence to the diet.
Epidemiologic studies have shown that adherence to MedDi is associated with reduced likelihood of diabetes, stroke and cardiovascular incidents, rheumatoid arthritis, and cancer. Two recent meta-analyses suggest that adherence to MedDi not only reduces risk for the aforementioned conditions, but also for Parkinson’s and Alzheimer’s diseases. This effect appears to be directly mediated by MedDi’s constituent nutrients and/or indirectly mediated by concomitantly reduced intake of foods present in the so-called “Western diet” (also known as the high saturated fat/refined sugar [HFS] diet).