Sunday, November 30, 2008

Magnesium Combination Treatments for ADHD

The previous 3 posts have all addressed the role of magnesium in the causes and treatment of ADHD and related disorders. Here I will address some of the guidelines as to how to boost the effectiveness of magnesium treatments in ADHD patients. This will include information on which forms are the best and which other compounds or nutrients, when used in combination with magnesium, can help the absorption and processing of this key mineral. Please keep in mind that these are recommendations and findings compiled from hundreds of medical journal articles and clinical studies. Do not take these suggestions as medical advice until you consult with your physician!

Some guidelines are listed below:

  • Based on age, gender and a few other factors, recommended amounts of magnesium levels range from 80 to 420 mg/day. For a detailed breakdown on the amount recommended for you, please check out this link here. Due to the role of estrogen, which helps in the retention of magnesium, females typically require less of this nutrient than males.

  • Several forms of magnesium are available. These include magnesium chloride, magnesium oxide, magnesium lactate and magnesium aspartate. A study on human absorption patterns showed that magnesium oxide had much poorer absorption than the other three forms. Other forms include magnesium sulfate, magnesium hydroxide, magnesium acetyltaurinate, magnesium citrate, and magnesium carbonate.

  • Of potential interest is the form magnesium acetyltaurinate. This form contains both magnesium and a chemically modified version of the substance taurine. Taurine, which is often seen in energy-boosters and “memory” drinks, has been shown to aid the absorption of magnesium into cells in mammals (as do several other compounds such as vitamin B6). It is important to note that this study was done in rats as opposed to humans, but, due to the high crossover of nutrient absorption and metabolism between the two species, I feel that this finding is at least worth mentioning. Although a rarer (and often more expensive) form of the mineral, magnesium acetyltaurinate may essentially provide “two-for-one” deal, thereby making it superior to other magnesium forms. Note that this conclusion is merely hypothetical at this point and should be treated as such. Nevertheless, with the support of your physician, it may be a strategy worthy of investigation for treatment of ADHD and related disorders.

  • In a recent post, we have seen how elevated levels of the compound kynurenine can lead to numerous difficulties and exacerbate the symptoms of ADHD and related disorders. A derivative of niacin (short for nicotinic acid or vitamin B3), which is called nicotinamide, has been shown to reduce the unwanted high levels of kynurenine, especially in the brain. Additionally, it has also been shown to reduce spasms in the blood vessels, thereby improving blood flow to the brain and reducing the likelihood of a brain hemorrhage and stroke. These findings are summarized in a journal article by BL Grimaldi (an abstract of the article can be found here).

  • As previously mentioned, vitamin B6 (pyridoxine) can boost the absorption of magnesium. We have seen in an earlier post that zinc can be used to boost the effectiveness of methylphenidate (Ritalin, Concerta), in certain cases. Additionally, zinc is required for optimal function of certain enzymes needed to process vitamin B6 such as pyridoxal kinase. Not surprisingly, zinc deficiencies are common in individuals with ADHD and related comorbid disorders. Vitamin B6 boosts the effectiveness of magnesium, vitamin B3 helps offset the buildup of unwanted levels of kynurenine, which is often seen in magnesium deficient individuals, and zinc aids in the processing of vitamin B6. Thus we're beginning to see how all of these vital nutrients do not act merely in isolation, but rather how they can work together to reduce the negative symptoms of ADHD and related disorders.

  • We have seen above that vitamin B3 can offset the buildup of unwanted kynurenine, which can be induced through magnesium deficiency. However, there are other key nutrients which are often reduced through prolonged periods of inadequate magnesium intake. Depleted levels of many antioxidants are often seen and need to be replenished. Among these are vitamin C, vitamin E and glutathione.

  • Glutathione, which is manufactured in the body, is among the most widespread and potent antioxidants used in the body. However, in order to stay in it's "de-oxidized" functional form, it needs help from dietary antioxidants. Vitamins C and E work with each other as well as with glutathione to keep adequate "pools" of glutathione available for the body's natural antioxidant defenses. Inadequate levels of glutathione can lead to the onset of numerous diseases, damage to the outer covering of cells and tissues, allergies, asthma, neural dysfunction and a wide array of other disorders. Magnesium deficiencies place unwanted stress on the body and reduce the body's available levels of glutathione. Thus, vitamin C and E are needed to "repair" this damage. Recommended levels of these two vitamins can be found here for vitamin E and here for vitamin C. These levels reflect recent changes in which the recommended doses of both vitamins have been bumped up.

  • ***Blogger's note: You may have read a number of references or seen a number of websites for ADHD and multiple other ailments touting the benefits of compounds such as pycnogenol (also known as French Maritime Pine Bark Extract), and grape-seed extract. As of now, I am neutral as far as using products such as these. However, it is important to note that the majority of the benefits derived from treatments such as these are due to their antioxidant effects, which are quite powerful by the way (however, other functions besides mere antioxidant effects have been suggested and are entirely possible). Additionally, these supplements can be quite costly. It is this blogger's opinion that similar effects and benefits can be seen with vitamin C and E supplementation for a cheaper price. Nonetheless, the large number of studies supporting the effectiveness of pycnogenol and grape-seed extract does warrant further investigation and potential success as an ADHD treatment option. With you're doctor's permission, pycnogenol or grape seed extract may be worthy of a trial run.

  • One final ingredient which is highly recommended for adding to the "pile" of nutrients for ADHD and related treatments is lecithin. The reason I personally hold in in such high regards is that it restores multiple components which may have been compromised by prolonged magnesium deficiency. Among these are essential omega 3 fatty acids (which are often found to be compromised in a wide range of diseases and disorders such as depression, heart disease, asthma, allergies, blood clotting and strokes, ADHD, multiple other neural disorders, Tourette's, chronic inflammation, and a whole slew of other ailments) such as alpha-linolenic acid, which is sometimes abbreviated as ALA.

  • Additionally, lecithin provides rich levels of inositol which is a special type of sugar which is often listed as a B-vitamin (however, by definition, it is not, since inositol, unlike vitamins, can be synthesized in the body. Nevertheless, it functionally behaves in a manner similar to several other B vitamins and is therefore sometimes classified as such), as several key agents necessary for proper cellular structure and neuronal function. These agents include phosphatidylcholine (which is needed to maintain cell structure, helps regulate breakdown of fats, and is also used to help cells communicate with each other), phostphatidylinositol (which is also required for cell communication or signaling), and phosphatidyl ethanolamine (which is a fatty tissue found in high concentrations in the brain, spinal cord and throughout the nervous system). Inositol itself is also a key "messenger" by facilitating cell-cell communication.

  • In addition to their utilization for cell structure and cell membrane integrity, some of these agents (namely inositol) have been shown to be effective antidepressants, having similar effectiveness and modes of action to the SSRI (selective serotonin re-uptake inhibitor) class of antidepressant medications. A summary of some of these findings can be found in a review by Grimaldi (abstract of article listed here). There is no official recommended amount for lecithin, but two tablespoons of the granular form are often administered by physicians. For good natural sources of lecithin, please click here.

  • While it provides many absorption-related benefits, magnesium can reduce the absorption and effectiveness of certain antibiotics such as tetracylcine. If you are taking this antibiotic for a short period of time, you may want to consider temporarily reducing your magnesium intake/supplementation.

  • Additionally, people with kidney disorders often have difficulty processing and removing magnesium from the system. It is imperative that this is discussed with a physician before deciding on magnesium supplementation.

The main idea of this post is to introduce to you the importance of including all of the pieces of the nutrient puzzle for treating ADHD and related disorders. A quick list of nutrients which must often be used in conjunction include: magnesium, vitamin B6, vitamin B3 (niacin), zinc, antioxidants (vitamin C and E, pycnogenol, grape-seed extract), and multiple components of lecithin (inositol, omega-3 fatty acids, and neuro-regulating agents and their derivatives). To summarize:

  1. Magnesium deficiency is thought to be a common underlying cause to ADHD and related comorbid disorders. Increasing magnesium intake via diet or supplementation can offset some of these problems. Recommended magnesium levels and natural sources can be found here.
  2. Vitamin B6 boosts the uptake of magnesium into cells. Additionally, an enzyme which helps absorb vitamin B6, called alkaline phosphatase, requires magnesium to function properly. Therefore, vitamin B6 and magnesium function in a cooperative manner, and enhance each other's effectiveness. Recommended vitamin B6 levels and natural sources can be found here.
  3. In addition to magnesium, several enzymes required for the processing and proper metabolism of vitamin B6 need adequate zinc levels to function properly. Recommended zinc levels and natural sources can be found here.
  4. Deficiencies of magnesium can lead to a harmful buildup of kynurenine. Treatment with vitamin B3 (niacin), can offset some of these harmful effects. Recommended vitamin B3 (niacin) levels and natural sources can be found here.
  5. Magnesium deficiency can cause a depletion of antioxidants (especially glutathione) in the body. Increasing the intake of antioxidants such as vitamin C and vitamin E (which complement each other and work great together in tandem), grape-seed extract or pycnogenol can replenish and restore the proper antioxidant balance to the system. Recommended levels and natural sources can be found here for vitamin C and here for vitamin E. No official levels for grape-seed extract or pycnogenol have been established, but common treatment levels and dosage information can be found here for pycnogenol and here for grape-seed extract.
  6. Low magnesium levels can also result in depleted amounts of several key fats or fatty-like substances necessary for proper nerve (as well as other types of) cell structure and function, as well as proper cell-cell communication. Lecithin is a great source of many of these deficient components, and is a good replacement method of treatment. There is no official recommended daily amount for lecithin, but for more information on common dosage levels of lecithin please click here.

You have hopefully seen how these key ingredients all work together and how a deficiency in even one of these can inhibit the effectiveness of the other nutritional agents.

Keep in mind that all of these can be obtained from natural food sources. It is not my intention to turn anyone into a "supplement popper". However, if your dietary patterns leave you prone to deficiencies in any of these nutrients, I do recommend supplementation. However, please check with your doctor before doing any of these treatment suggestions. Also, keep in mind that this list is not extensive. I will be discussing some other essential nutrients (such as iron, whose low levels are often connected to ADHD and related disorders) in future blog posts.

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Thursday, November 20, 2008

Dietary Magnesium and ADHD Comorbid Disorders

This is the third in a three-part series on the effects of magnesium intake on ADHD. We have seen previously how ADHD can be associated with dietary magnesium deficiencies, and how supplementation with magnesium can prove helpful. We have also seen that taking in vitamin B6 can boost magnesium's absorption into cells, improving its effectiveness for treating ADHD. The co-dependence of magnesium and vitamin B6 is reciprocated, as the enzyme alkaline phosphatase helps absorb the usable form of vitamin B6 into tissues in the body. This important enzyme requires magnesium to function properly.

We have also seen in previous posts that ADHD is often not an isolated condition. Accompanying symptoms such as Tourette's, bedwetting, sleep disorders, depression, allergies and an array of other comorbid disorders are often seen alongside ADHD. Some of these disorders also show statistically-low blood levels of key nutrients. Although this does not guarantee a common underlying nutritional deficiency as the root cause of both ADHD and these other disorders, it does suggest that we give a closer look to some of these overlapping factors.

In the case of ADHD and Tourette's, we see a shared deficiency in the essential mineral magnesium. Keep in mind that Tourette's has a huge overlap with both the OCD (Obsessive Compulsive Disorder) and ADHD. In fact, some estimates place up to 90% of individuals with Tourette's in the ADHD category. While I personally find that figure to be a little high, it is important that we see the magnitude of overlap of these two comorbid disorders, especially since they both share a noticeable connection with low magnesium levels.

Most of this post draws from information from an article in the journal Medical Hypotheses by BL Grimaldi. A summary can be found here. As the name of the journal suggests, this information is not based on a controlled clinical study, but rather a literature investigation combing through over a dozen different disorders and abnormalities commonly associated with Tourette's. ADHD is one of them, as are other common ADHD comorbid disorders such as allergies, Restless Leg Syndrome, seizures, depression, migraine headaches, teeth-grinding and obsessive compulsive disorder.

While all of these symptoms have some sort of connection to a magnesium or vitamin B6 deficiency, three of the strongest tell-tale signs are migraine headaches, allergies (especially on the skin), and hypersensitivity/hyperexcitability (negative over-reactions to stimuli such as touch. Erratic, jerky movements (not seizure-like, or tic-like, but rather rigid, jerky movements in he body, and the hands in particular) can also be caused by low magnesium levels. A study on magnesium-deficient rats showed high levels of inflammation and redness, especially in the ears. While a similar study (at least to the best of this author's knowledge) has not been done on humans, the prominence and rapid onset of this potentially key tell-tale sign should not be overlooked.

Some other key findings of the article are listed below:

  • There is a genetic region on the 11th chromosome called 11q23 which has been linked to both magnesium retention and loss as well as Tourette's. Interestingly, this genetic region is relatively close to another region called 11q22, which is possibly connected with ADHD, based on some studies. This suggests that, the magnesium deficiency connection may not be entirely dietary, as there may be an underlying genetic factor at work behind low magnesium levels, Tourette's and ADHD. This relationship is relatively strong with magnesium and Tourette's, with the relationship with ADHD being more tenuous.

  • We have seen in the last post how vitamin B6 and magnesium serve as complementary ADHD treatments. Additionally, this article mentions that both these key nutrients are essential for an important enzyme called kynurenase. Kynurenase breaks down the compound kynurenine. We do not want to have high levels of kynurenine around, because high levels of this interfere with the balance of a number of brain chemicals which, at imbalanced levels are connected with ADHD, Tourette's and various other related disorders. Two of these important brain chemicals that need to be balanced are GABA (which will be discussed in future posts) and dopamine, which are extremely important neurochemicals tied in to ADHD in a number of different ways.

  • Additionally, low levels of kynurenase (and thus high levels of kynurenine) can indirectly result in low levels of the important brain chemical serotonin (which is very important for both specific types of ADHD as well as depression and Obsessive Compulsive Disorders). Several individuals with specific types of ADHD or depression take the supplement L-tryptophan, which is converted to serotonin in the body. Low levels of the enzyme kynurenase can result in a poor tryptophan to serotonin conversion, so inadequate kynurenase levels can invalidate L-tryptophan supplementation effectiveness. Therefore, low levels of magnesium and vitamin B6 can result in compromised activity of a key enzyme that helps maintain balanced levels of important chemicals in key brain regions which are often unbalanced in individuals with ADHD.

  • Hormonal surges, especially those that occur during puberty (such as testosterone), can also can lead to an unwanted increase in kynurenine (see previous 2 points for the negative effects of this). This is especially true for vitamin B6 deficiencies. Therefore, it it imperative that adolescents, especially those with or prone to disorders such as ADHD, OCD or Tourette's to make sure they have adequate levels of vitamin B6, either through diet or supplementation. Additional information on sources and recommended levels of this vitamin can be found here.

  • Additionally, kynurenine can result in constriction of blood vessels, reducing blood flow to key areas. Since individuals with ADHD often have restricted blood flow to specific brain regions (the frontal region behind the forehead is a common site), higher levels of kynurenine due to magnesium and vitamin B6 deficiencies can contribute to or worsen one of the underlying causes of the disorder.

  • Finally, high levels of kynurenine can increase uncontrolled hyperactive behavior and amplify some of the negative effects of caffeine.

  • In addition to affecting serotonin levels, low magnesium levels can alter the targets of serotonin, also called serotonin receptors. This can result in migraine headaches, making migraines a possible warning sign of low magnesium levels (it is suggested that up to 50% of migraine cases are connected to significantly low levels of a key form of magnesium).

  • For Tourette's-like behavior, stimulant medications used to treat ADHD can exacerbate tics and other symptoms of Tourette's (see a related post on this topic here). This may pose as a problem for the large number of individuals who suffer from both Tourette's and ADHD. These effects are magnified even further if the individual is under some type of physical or emotional stress. Unfortunately, low magnesium levels can also prolong stress or anxiety by tripping some key target regions in the brain such as the amygdala (which is located in the center of the brain and is an important site of emotions and memory generation). As a result, low magnesium levels, combined with ADHD stimulant medications can both lead to and increase the duration of negative anxiety and stress in the body. This in turn can worsen tics and other negative symptoms associated with Tourette's Syndrome.

  • Following approximately 2 weeks of magnesium deficiency, histamine and other pro-inflammatory agents begin to appear. The result is often some type of allergic reaction. Not surprisingly, allergies are a common side effect of both ADHD and Tourette's. Interestingly, some of these agents, such as histamine, can counteract some of the functions of vitamin B6, thereby propagating the negative magnesium/B6 deficiency cycle. On top of this, the heightened allergic response can stimulate the anxiety regions in the brain (see the previous point), which in turn, boosts prolonged anxiety and stress levels even further.

  • Finally, low magnesium levels can trigger a product called Substance P, which, among other things, can boost itching of the skin, the desire to use profanity (one of the less-frequent, but most-associated signs of Tourette's), and even unhealthy sexual obsession. Not surprisingly, individuals with both Tourette's and ADHD are much more prone to risky sexual behavior. Substance P also reduces the body's ability to absorb an important nutrient called inositol, which is essentially a cross between a sugar and a B vitamin. Inositol plays a number of critical roles, including neural function, balancing fat stores in the liver, detoxifying the body, and preventing cholesterol buildup in arteries. As we can see, reducing the presence or activity of this key nutrient and limiting its absorption into cells due to magnesium and vitamin B6 deficiencies (as well as other factors) can have prolific and far-reaching negative effects on many of the body's systems.

Due to the current length of this post, I will stop here. In the next post, I will wrap up a few more things with magnesium and accompanying nutrients and their critical role in ADHD and related disorders. I just wanted to highlight the fact that these effects are far-reaching, and can have serious implications in the overall health of an individual. One month ago, I knew next-to-nothing about the many roles of magnesium, but as of now, I consider it one of the most underrated nutrients out there. Stay tuned for the next blog post, where we will discuss which forms of this key mineral are the best for supplementation, as well as which other ingredients to take alongside of it to maximize its effectiveness for treating ADHD and some of its comorbid disorders.

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Tuesday, November 18, 2008

Treating ADHD with Magnesium and Vitamin B6

In the last post, we examined how magnesium levels are tied to ADHD and how supplementation with magnesium can potentially help for the disorder. We will be adding one more step to this process by including the role of vitamin B6 into the mix of magnesium treatment for ADHD. Vitamin B6 has been shown to improve the absorption of magnesium as well as other minerals into cells, allowing higher levels of this key mineral to be attained. Essentially, this allows smaller doses of magnesium to be taken by making the intake process more efficient. Additionally, B vitamins have their own set of properties and numerous studies have linked the B vitamin family to improved mental function.

A study was done on the effectiveness of the Magnesium/Vitamin B6 combination treatment for ADHD. While the subjects of this study were young children, many of these results can carry over to adult cases of ADHD. A quick synopsis of the original publication can be found here. I will summarize some of the key points here:

  • Individuals with ADHD have lower than normal levels of magnesium inside their blood cells than do individuals without the disorder. However, magnesium levels in the serum (liquid part of the blood which does not include the blood cells) were not tied to ADHD. Since Vitamin B6 helps get the magnesium into the blood cells, it is a key ingredient in treating ADHD with Magnesium.

  • Low magnesium levels can also lead to irritability (which is also a potential side effect of Vitamin B6 supplementation by itself. This is another reason why taking Magnesium and B6 together can be useful). Hyperactivity, inattention, aggressive behavior and sleep problems are also associated with low magnesium levels. It also has been tied to reduced blood flow to the brain, which is a common phenomena frequently seen in brain scans of ADHD individuals.

  • Treatment with magnesium and vitamin B6 reduced negative symptoms of inattention, aggressiveness and hyperactivity in a study of young children (average age around 6-7 years old). The amounts used were 6 mg/kg/day for magnesium and 0.6mg/kg/day for vitamin B6. This is roughly 100-200 mg of magnesium, which is in line with the recommended amounts (see here for these numbers) and around 10-20 mg for Vitamin B6.

  • Although most ADHD symptoms were improved with Magnesium/Vitamin B6 treatment, the most improvement was seen in hyperactivity. Thus this Magnesium/Vitamin B6 treatment combination would likely have the most success in the Hyperactive Impulsive or Combined ADHD subtypes.

  • Symptom improvements were seen the most in individuals who had higher (closer to normal) magnesium levels to begin with. This suggests that there may be some type of minimum threshold in cells or tissues that must be attained to achieve the desired results. This supports the idea that Magnesium/Vitamin B6 should be more of a long-term treatment strategy for ADHD, as opposed to a "quick fix".

  • It also suggests that it may take awhile (2 months or more, based on some of the study's parameters) for the full effectiveness to kick in. This was further supported by the fact that when treatment was discontinued, the undesired ADHD symptoms returned within a few weeks. The good news behind this is that missing a day will not have the pronounced immediate effects of missing a day of a stimulant medication for ADHD.

  • Speaking of stimulant medications, the article referenced other studies which noted that stimulant medications such as dextroamphetamine and methylphenidate boost magnesium levels in the blood. This is important to note, especially for individuals who already take ADHD stimulant medications. It is possible that combining these meds with magnesium/vitamin B6 supplementation can lead to magnesium levels above the upper limit. Please consult your physician before taking Magnesium/Vitamin B6, especially if you are already taking stimulant medications for ADHD. For more information on magnesium overdose and its symptoms, please click here.

This study presents compelling evidence that deficits in just one mineral can be a major factor in the onset of ADHD. It also suggests that a relatively simple treatment via slight dietary changes or supplementation can produce significant results in treating ADHD. Although the study had some flaws (relatively short duration, few test subjects and minimal placebo controls), the results are difficult to overlook.

In our next post, we will investigate the role of magnesium in some of the other disorders that frequently occur alongside ADHD, also known as ADHD comorbid disorders.

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Sunday, November 16, 2008

Magnesium Deficiency and Childhood ADHD

Magnesium Levels and the Connection to ADHD
In the last blog post, we talked about how an iodine deficiency in pregnant women can lead to ADHD and other cognitive dysfunctions in children. Iodine is just one of the many key nutrients that have been correlated with a worsening of ADHD-like symptoms. The effects of deficiencies for more well-known minerals such as iron and zinc are widely published. Low levels of both of these minerals have been associated with the onset of ADHD, and will be discussed in later posts. However, a lesser-known but equally important mineral relevant to ADHD and overall brain function is magnesium. There have been multiple studies linking low levels this key nutrient to an increased onset of ADHD.

Signs and Symptoms of Inadequate Magnesium Intake
Magnesium actually shares a functional overlap with iodine as far as proper bodily function is concerned. It plays a crucial role in maintaining function in a number of enzymes and other essential proteins. Additionally, like iodine, magnesium is essential for adequate bone health as well as maintaining adequate body temperature and energy levels. There are a number of signs of magnesium deficiencies which actually mask symptoms of other diseases, but some of the most distinctive signs of low magnesium levels are unexplained ulcers in the mouth area. Additionally, while allergies and asthma occur at higher levels in individuals with ADHD as comorbid disorders, the presence of ADHD, allergies, asthma and fibromyalgia (high levels of constant pain and sensitivity to touch) can be due to inadequate magnesium levels in the body.

Frequency of Magnesium Deficiencies and Recommended Daily Amounts
Like iodine, magnesium deficiencies are relatively common in industrialized countries. In children, these trends are even more ominous, with some estimates placing up to 90% of children in the magnesium deficient category. Recommended amounts typically fall within 280 to 400 mg per day, with men requiring slightly higher amounts than women. Seeds and nuts are among the best sources of this vital nutrient, with one of the best options being pumpkin and squash seeds (1 ounce provides about a third of the recommended daily amount).

**Please keep in mind that the recommended magnesium levels of 280 to 400 mg are for adults and older children. For newborns (around 30 mg/day) to children under 9 (130 mg/day), the requirements are lower. While there are no "food-based" upper limits for magnesium, there are for supplements. This is due to in part to different absorption patterns of the different magnesium forms in supplements as opposed to foods. Please click here to see some tables for recommended and upper limits of magnesium for children. Also, keep in mind that certain antacids and laxatives contain high levels of magnesium already, so please follow the upper limit max for supplements.

Treating ADHD with Magnesium Supplementation
Given the relatively low consumption of these foods by individuals in westernized countries, as well as the prevalence of nut allergies, supplementation with magnesium is another good option.
While both of the main components of ADHD (inattention and impulsivity/hyperactivity) are both associated with low levels of magesium, it appears that the hyperactivity factor is even more pronounced. The effectiveness of magnesium treatment is boosted by another key nutrient in the family of B vitamins, namely Vitamin B6. My next blog post will go into more detail about this treatment combination for ADHD.

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Thursday, November 13, 2008

Iodine deficiency or ADHD?

We have alluded to the fact in previous posts that ADHD symptoms can sometimes either be triggered or mimicked by nutrient deficiencies. If this is the case, then we can argue that by increasing the levels of these nutrients via food intake or supplements could ameliorate some of the negative features of the disorder.

While vitamin, mineral, protein and omega 3 fatty acid deficiencies often steal the spotlight for dietary intervention strategies for ADHD, there is another, less-heralded connection and treatment that deserves considerable attention. According to multiple journal articles, reviews and studies, there appears to be a correlation between an iodine deficiency and an increased likelihood of developing ADHD.

One such study on ADHD and iodine was published in the Journal of Endocrinology and Metabolism in 2004 by Vermiglio and coworkers. This study found that mothers who were iodine deficient were more likely to give birth to children with ADHD. While numerous nutritional deficiencies are often predominantly linked to Third World countries, Iodine deficiencies are surprisingly common in industrialized nations. Although little attention is often paid to this topic, the results of an iodine deficiency can be quite severe.

Since the thyroid gland and the hormones it secretes are heavily dependent on this key nutrient, low levels of iodine can lead to problems such as poor circulation and body temperature regulation, reduced energy levels, inhibited brain development and dysfunction, improper calcium levels in the blood and bones, and impaired immune function.

In a nutshell, the study examined the rates of ADHD in children who lived in 2 different regions, a relatively Iodine-rich region (where iodine deficiencies were more commonplace) and and Iodin-poor region. The 10-year study, which had a relatively small sample size, found that the rates of ADHD born to mothers at risk for facing an iodine deficiency was significantly higher than the rates of those born to mothers in a more iodine-sufficient environment. Furthermore, IQ scores were statistically lower in the low-iodine group.

We need to be careful not to lump ADHD into a general category of cognitive decline. After all, a very large percentage of individuals with the disorder are of average or above-average intelligence.

The overall mechanism of low iodine and the onset of ADHD is not completely clear, but there is a known correlation between low hormone levels (those secreted by the thyroid gland) and ADHD. Other studies, including one in the New England Journal of Medicine, have shown that individuals with a built-in resistance to thyroid hormones have higher incidences of ADHD. Individuals with a specific genetic mutation to the thyroid receptor-beta gene, are resistant to specific thyroid hormones and have roughly 3 times the risk of developing ADHD than the general population.

In the low iodine study, it appears that there was a bias towards hyperactive and impulsive behavior (as opposed to inattentive behavior), but with the small sample size used in the study, we should not put too much weight into this possible connection. Nevertheless, it is at least worth mentioning. Additionally, abnormal weight gain can also be a sign of an iodine deficiency, so an unexplained increase in weight accompanied by an increase in ADHD symptom severity may be due to an iodine deficiency and thyroid dysfunction.

Simple clinical tests can be done to determine whether an individual is iodine deficient and/or has thyroid dysfunction. One of the most common measuring devices is testing for the levels of TSH or Thyroid Stimulating Hormone. If an individual has underactive thyroid function (such as that caused by insufficient iodine intake), then the body tries to compensate for this by boosting thyroid function through increasing levels of TSH. Therefore, high levels of TSH correlate with an abnormally low thyroid function. Not surprisingly, in the pregnancy study on ADHD and iodine deficiency, mothers of ADHD children typically had elevated levels of TSH.

So how do we boost dietary iodine levels quickly and efficiently (the recommended daily amount is 150 micrograms, if that number means anything to you!)? One of the easiest ways is to replace common refined table salt with either iodized salt, or iodine-rich sea salt. Ocean fish and seaweed are also good bets as iodine-rich food sources.

One particularly good piece of information is that the developing fetus is surprisingly resilient to early stages of iodine deficiency in the mother if the iodine deficiency is corrected before the third trimester of pregnancy. Since the effects of an iodine deficient diet can be severe to both mother and child, I highly recommend pregnant mothers to switch to iodized salts or sea salt during the pregnant and nursing stages. This simple practice can significantly reduce the risk of ADHD and cognitive dysfunction in their child's future.

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Tuesday, November 11, 2008

Natural Treatments to Try Before ADHD Medication

We have been spending a lot of time recently on medications for ADHD. However, one question we should always be asking ourselves is: "Are medications always necessary?".

Believe it or not, there are a number of nutritional deficiencies that can trigger ADHD-like symptoms or worsen the disorder. There are definitely instances where merely fixing key nutritional imbalances over a period of a few weeks can lead to positive results.

Before we go any further, we need to examine how this all works out. It helps to think of ADHD as a puzzle, where one or more pieces are missing. If we can correctly fill in the missing puzzle piece(s), then we can treat the disorder. Of course this is oversimplifying it a bit, and no, nutritional and "natural" strategies do not always work. Nevertheless, I believe they are grossly under-utilized. After all, if a vitamin supplement gave the same results as an amphetamine-based drug, which one would you choose for you or your child? The answer is a no-brainer.

Based on a keynote article on Ritalin vs. supplement treatments for ADHD, which is frequently cited by the "natural cures for ADHD" crowd, we see compelling (albeit limited) evidence that natural supplementation can be as effective as Ritalin for treating ADHD. It sounds intriguing, but it is also important to note that too much weight is often placed on this study. Why? Because all of this information is based on the results of only 20 individuals (10 whom took the Ritalin and 10 who took the dietary supplements). Of course we should not discount the research because of a small sample size, but out of the millions who suffer from ADHD, do we really want to hinge a bunch of expectations on 20 individuals? Nevertheless, the results are worth reporting and are due much further investigation.

Here are 9 different possibilities cited by the article for nutritional deficiencies or environmental factors which could affect the onset of ADHD (I subdivided one of the categories, there are only 8 in the original article). I will list them here, and investigate each one in more detail in later posts:

  1. Food allergies and food additives
  2. Toxic effects of heavy metals or environmental contaminants
  3. Protein-carbohydrate imbalances
  4. Mineral deficiencies or imbalances
  5. Fatty acid deficiencies or imbalances
  6. Amino acid deficiencies or imbalances
  7. Thyroid dysfunction and iodine deficiencies
  8. B vitamin deficiencies
  9. Antioxidant levels, including phytonutrients and polyphenols (found in fruits, vegetables, coffee, teas, wines, beer and a few other sources).

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Monday, November 10, 2008

Increasing Concerta Medication Dosage: Benefits and Risks

In the last post, we introduced the concept of dosage windows for ADHD medications. In other words, we see that the dosage level of an ADHD medication can be of equal importance to the type of medication used. For more info on this topic, please check out the blog site of Dr. Charles Parker called CorePsychBlog. It is extremely well-organized, concise, and easy to follow, in my humble opinion. This is where I was first introduced to the "window" concept of medications, the term which I have borrowed for the last couple of posts.

This post is meant to expound on the dosage principle in the context of on of the more popular ADHD stimulant medications currently on the market, Concerta (slow-release methylphenidate). We will be drawing information from a few key articles, including one from the 2003 Journal of Pediatrics by Mark A. Stein and coworkers. A copy of the original online journal containing a summary of this article can be found here.

If you do not have time to read all of this post, feel free to skip to the last paragraph at the bottom of the page to get the overall message of this blog entry. If you are looking for more detail, I have addressed the key points made in this article in the major points below:

  • The drug Concerta releases the active methylphenidate ingredient into the system at slowly increasing levels over roughly a 12-hour period. The overall effect is similar to that of the traditional tri-daily methylphenidate medication.

  • The article studied the positive and negative effects of this medication in 5 to 16 year-old children under three different common prescription doses, 18, 36 and 54 milligram doses. These children were of average or above-average IQ, with about 1/3 being diagnosed as Learning Disabled. About two-thirds of the children had never taken any type of stimulant medication for ADHD before the study.

  • Noticeable differences were seen between different ADHD subtypes. For the Inattentive subtype, lower levels doses were optimal, while for the Combined subtype (inattention plus impulsive behavior plus hyperactivity), higher amounts were typically optimal. When the effects of co-occuring disorders such as oppositional defiance (ODD) and learning disabilities were factored out to focus in the ADHD itself, the subtype differences were even greater. This underscores the need for proper subtype diagnosis as opposed to just labeling an individual ADHD.

  • For the Primarily Inattentive (PI) subtype of ADHD, the inattention difficulties improved most dramatically with the first 18 mg of medication. Beyond this dosage, only slight effects were seen. This is in agreement with another earlier study which analyzed different doses of another form of methylphenidate for treating ADHD. For the accompanying hyperactivity and impulsive behavioral symptoms (which are often present in the inattentive subtype, just not at the same elevated level of the Combined subtype) were most effectively reduced with the first 18 mg of the medication. While the effectiveness of higher doses leveled off, slight but noticeable improvements were also seen as medication dosage was increased from 18 to 36 mg. At 54 mg, however, improvements stopped or even regressed. This suggests that the "sweet spot" for the Inattentive Subtype of ADHD is somewhere around 18 mg (or slightly higher). Note that Concerta is also available in the 27 mg level, a dosage which was not tested in the study.

  • In contrast to the Inattentive Subtype, where the greatest gains were seen from 0 to 18 mg of Concerta, for the Combined Subtype of ADHD, the greatest overall boost in effectivness was seen between 36 to 54 mg. Based on the trends of the graphs in the paper, as well as data from other studies, it appears that doses beyond 54 mg may still be of benefit for several individuals with the combined subtype. In other words, treatment of individuals with the Combined ADHD Subtype typically requires at least 18 mg more medication than those of the Inattentive Subtype (see note at end of the post for an important caveat and exception to this).

  • Negative side effects of the medication were minimal at low (18 mg) to middle (36 mg) doses. However, beyond 36 mg, these negative side effects became more pronounced.

  • Sleep problems (such as insomnia) began at the 36 mg dosage for Concerta, with the most pronounced effects seen in younger and smaller children.

  • Noticeable appetite suppression was seen even at low doses (from 0 to 18 mg), especially for younger and smaller children. However, the overall severity of this was limited. However, the percentage of children who experienced "severe" appetite suppression dramatically increased between 36 to 54 mg treatments of Concerta.

  • At 36 mg, the presence of or increase in tics (see related post on ADHD and tics) was seen, and a further increase was seen for some children at the 54 mg dosage.

  • A much earlier study on the ADHD medication methylphenidate (an earlier non-Concerta form) suggested that while hyperactive behavior continued to improve at higher doses, the ability to perform cognitive tasks decreased at higher levels of medication. While these effects were difficult to duplicate in future studies, it does suggest an upper limit for certain medications in which going above may lead to a reduction in improvement. We have seen similar effects in previous posts (see the "upside down U curve" in point #6 for tyrosine and clozapine treatment for ADHD here as an example).

A caveat and final blogger's note: Based on the conclusions of the study, it appears that going above the 54 mg limit may be beneficial for certain individuals of the Combined Subtype. While the data of the study may support this, it is important to note that the study only lasted 3 weeks. As a result, long-term effects of high doses of medication were unable to be observed. Additionally, we saw in one of the points above that negative side effects began to creep in at the 36-54 mg level. Based on other blog posts with regards to risk factors of certain ADHD medications as well as potential medication side effects, I urge you to err on the side of caution, especially on issues concerning young and small children (who are at much greater risk for developing severe side effects). In the above study, the highest dosage (54 mg of Concerta) was omitted for the smallest study participant as a precautionary measure.

A quick overall summary of this post: It is imperative that we take ADHD subtype seriously. The take-home message of this blog post should be that lower doses of methylphenidate are often optimal individuals with the Inattentive subtype for ADHD, while those of the Hyperactive-Impulsive (not studied in the above journal article) and Combined subtypes of ADHD typically require significantly higher levels of medication.

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Friday, November 7, 2008

ADHD Medication Dosage Windows

Blogger's note: I was first introduced to the concept of a "window" in the blog of Dr. Charles Parker. I highly recommend it. A link to his site, CorePsychBlog, can be found here. I would like to borrow his "window" analogy, as I think it is a very relevant description for what is going on here.

We have spent quite a bit of time discussing the different medications for treating ADHD. Recent attention has been given to methylphenidate (Ritalin, Concerta, Daytrana) treatment. While the choice of drug is extremely important for treating ADHD, there is often a less discussed, but equally important, factor for medication treatments: the actual dosages used. Of related interest is the timing effect of ADHD medications. If you are interested in the need for proper timing for ADHD medications, please visit the site here.

In treatment areas such as homeopathic medicine, we see that specific volumes and concentrations of the desired compounds are essential for the effectiveness of the agent used. In these treatments, treatment effectiveness depends on extremely low concentrations of the treatment agent being used.

While there are stark differences between standard ADHD medications and homeopathic remedies, it is important to realize one common overlapping factor the two treatments often share is overdosage is countereffective and often harmful. While this seems inherently obvious, it is important to note that "overdosage" here can refer to even a slight excess of medication, and is not limited just to exceedingly high amounts.

Going one step further, we even see that specific ADHD medications actually have completely different modes of action and completely different effects when taken at different dosage levels. For example, a 15 mg dose of Ritalin may not only be "overkill" for a patient who should be taking the 5 mg dose, but the extra 10 mg may actually offset or even counteract the benefits derived from the first 5 mg. We have seen similar effects in previous posts such as the one on tyrosine and clozapine. With regards to the medication and amino acid combination treatment, we see that tyrosine supplementation boosts the effectiveness of clozapine to a certain point, but beyond this point, excess tyrosine is counterproductive. Essentially, tyrosine supplementation follows an upside down "U" curve (see bullet point #6 in this post).

This same effect can also be seen in medications, especially when minimizing negative side effects is a concern. In other words, the ADHD medication dosage window is often extremely small. Given the fact that multiple other factors including diet, sleep patterns, other medications, co-existing conditions and health of the patient, etc. can all interfere with medication effects, it is no wonder that even at the right prescription doses individuals frequently shift between "on" or "off" days for medication-controlled treatments. In the next post, we will be examining the effects of different doses of the ADHD medication methylphenidate (Concerta).

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Tuesday, November 4, 2008

Using Zinc to Boost Ritalin's Effectiveness

We have seen that combining stimulant and non-stimulant medications for ADHD can be effective, as evidenced in a previous post on how Risperidone boosts ADHD stimulant medication effectiveness. We have also explored how supplementation with the amino acid tyrosine can boost the effectiveness of clozapine. Now we will be examining another non-medication compound, zinc sulfate and its effects on the popular ADHD drug methylphenidate (Ritalin, Concerta).

Most of the information in this post is gleaned from a 2004 article in the journal BMC Psychiatry on Zinc Sulfate and methylphenidate for children with ADHD. Some key points are listed below:

  • The study compared children with ADHD of both genders, ages 5-11 who took either: methylphenidate with zinc sulfate (15 mg zinc) to those who took methylphenidate by itself (with a sugar placebo) for 6 weeks. Results on treatment effectiveness were determined based on both parent and teacher ratings for ADHD behaviors, as well as psychiatrist evaluations every 2 weeks.

  • Zinc is required for the proper function of over 100 different enzymes in the body and previous research has shown that a deficiency in this important mineral can be associated with ADHD.

  • Zinc also helps regulate levels of the important compound melatonin, which plays a significant role in regulating sleep patterns in individuals both with or without ADHD. Melatonin also plays an important role in regulating levels of the brain chemical dopamine, which is a key factor in ADHD.

  • All children in the sample were of the combined subtype (one of the 3 major subtypes of ADHD, which includes hyperactivity, impulsive behavior and inattention), and had not received previous ADHD medications.

  • The study found that ADHD symptoms decreased following the 6 week period for the methylphenidate group, but an even more pronounced decrease in negative symptoms when the methylphenidate was combined with zinc. These trends were statistically significant in both the parent and teacher rating studies.

  • (Blogger's point, not from article): Based on previous studies and blog posts on the ADHD stimulant medication Adderall, we have seen that psychiatrists generally see even greater levels of improvements for ADHD treatments than do parents or teachers. If this trend holds true to this treatment, then it is possible that these positive effects may be under-representations of the real potential of zinc-methylphenidate combination treatment.

  • (Blogger's remark, not from article): While this study showed promise, it did not compare zinc-methylphenidate treatment to zinc treatment by itself. In other words, we cannot tell if zinc treatment actually amplifies the effects of the medication or if it simply targets additional symptoms of the disorder. Given the fact that zinc deficiency is common in individuals with ADHD, it may be the case that zinc supplementation, not methylphenidate may be the main effective treatment factor. Look for future posts on zinc supplementation and ADHD.

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