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Prostaglandins, Leukotrienes and Essential Fatty Acids 74 (2006) 17–21 Supplementation with flax oil and vitamin C improves the outcome of Attention Deficit Hyperactivity Disorder (ADHD) Kalpana Joshia,Ã, Sagar Ladb, Mrudula Kalea, Bhushan Patwardhana, Sahebrao P. Mahadikc, Bindu Patnib, Arti Chaudharyb, Sheila Bhaveb, Anand Panditb aInterdisciplinary School of Health Sciences (ISHS), University of Pune, Ganeshkhind, Pune—411007, Maharashtra, India bKing Edward Memorial Hospital (KEM), Rasta Peth, Pune 411011, Maharashtra, India cDepartment of Psychiatry and Health Behavior, Medical College of Georgia, Augusta, GA 30904-6285, USA Received 7 July 2005; received in revised form 17 September 2005; accepted 16 October 2005 Considerable clinical and experimental evidence now supports the idea that deficiencies or imbalances in certain highly unsaturated fatty acids may contribute to a range of common developmental disorders including Attention Deficit HyperactivityDisorder (ADHD). Few intervention studies with LCPUFA supplementation have reported inconsistent and marginal results. Thispilot study evaluates the effect of alpha linolenic acid (ALA)-rich nutritional supplementation in the form of flax oil and antioxidantemulsion on blood fatty acids composition and behavior in children with ADHD. Post-supplementation levels of RBC membranefatty acids were significantly higher than pretreatment levels as well as the levels in control. There was significant improvement in thesymptoms of ADHD reflected by reduction in total hyperactivity scores of ADHD children derived from ADHD rating scale.
r 2005 Elsevier Ltd. All rights reserved.
infants and the apparent conversion of ALA to DHA isdependent on both adequate level of ALA and a low Attention Deficit Hyperactivity Disorder (ADHD) is level of LA in the diet . ALA-rich flax oil could the most common behavioral disorder in children therefore be used as precursor supplementation for affecting about 3–5% school-going children. In an epidemiological study we have reported 10.4% ADHD The deficits in the attention, memory and motor skills prevalence in school children in Pune, India .
are also key features of the schizophrenia and improved It is well established that proper metabolism of certain treatment of these symptoms represents its improved long-chain polyunsaturated fatty acids (LCPUFAs), outcome suggestive of advantage of early interventions particularly arachidonic acid (AA) and docosahexaenoic The aim of the present study was to investigate effect acid (DHA) is critical for normal development of brain of flax oil and antioxidant supplementation on the . There have been considerable numbers of studies on symptoms of ADHD and compare EFA levels in essential fatty acids (EFA) supplementation to ADHD children. Although EFA supplementation has promisingsystematic case-control data, clinical trials are equivocaland require efforts to build definite evidence of a causal contribution Alpha linolenic acid (ALA) is now wellestablished to be a precursor fatty acid to DHA in This study was conducted in TDH Rehabilitation Corresponding author. Tel./fax: +91 020 25690174.
E-mail address: (K. Joshi).
Centre and Pediatric Department of KEM hospital, 0952-3278/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.plefa.2005.10.001 K. Joshi et al. / Prostaglandins, Leukotrienes and Essential Fatty Acids 74 (2006) 17–21 Pune. The study design was approved by the ethical committee of KEM and ISHS. Written consents of theparents were taken for recruitment of ADHD children.
Fasting venous blood was collected in tubes contain- The patients (N ¼ 30) enrolled were consecutive admis- ing EDTA at the time of enrollment of the subjects sions to outpatient treatment unit of Pediatric depart- including patients and normal controls after clinical ment of KEM hospital, Pune, India. Diagnosis of assessment. RBCs were separated by centrifugation, ADHD was done by trained clinical psychologist with coded and stored at À70 1C until used for analysis. The the help of Diagnostic and Statistical Manual (DSM) IV analysis was carried out blind to the subject status.
criteria (Guidelines given by American Association of Samples were then methyl-esterified using a revision of Psychiatry) . Stanford Binet test was used to find the original method of Manku et al. . Briefly, total mental age and intelligence quotient. Patients with lipids were first extracted using 2:1 chloroform/metha- WAIS-R full-scale IQo80 were excluded. The patients nol. The phospholipid fraction was prepared by thin and controls also were excluded for severe under or layer chromatography on silica-gel H plates developed malnourishment, seizures and head injury with loss of in petroleum ether/diethyl ether/acetic acid (90:15:1 by consciousness. Documentation of history, medical con- volume). Bands containing phospholipids were scraped dition, and assessment of hyperactivity scores pre- and into vials containing methanolic HCL (0.6 N HCl/ post-supplementation using pre-validated Parent Rating methanol) and esterified at 80 1C for 2 h.
Scale was done at the time of recruitment of both the These esters were separated and quantified using a Shimadzu (GC-17A) Gas chromatograph (SP-2330 30- Parent Rating Scale was based on DSM IV and m capillary column, Supelco). Hydrogen was used as a comprised of 30 variables such as Restlessness (R) 7, carrier gas at 1 ml/min. Oven temperature was held at Inattention (In) 6, Impulsivity (Im) 4, Self-control 175 1C for 15 min, programmed to rise from 175 to (SC) 8, Social Problems (SI) 4, Learning problem (I) 7.
220 1C at 10 1C/min, then held at 220 1C for 10 min.
Out of these six categories; added scores of R, In, Detector temperature was 275 1C and injector tempera- Im, and SC is considered as Hyperactivity-H score ture was 240 1C. Retention times and areas under the and SI and I together constituted the related problem peaks were automatically computed by an integrator.
Peaks were identified by comparison with standard fatty Normal controls (N ¼ 30) consisted of healthy acid methyl esters purchased from Sigma-Aldrich (St.
children enrolled from the general population and had hyperactivity scores below 50. They were mat-ched for age and gender, and belonged to the same ethnic background, and had similar lifestyleand dietary patterns. ADHD as well as NC blood TBARS were estimated as reported by Konings and samples were processed and analyzed in the same Drijver . Briefly, plasma proteins were precipitated using trichloroacetic acid. The sample was heated with Information on socioeconomic status (SES) and thiobarbituric acid at 80 1C for 30 min and the family dwelling was collected and scored on a simple absorbance read at 532 nm. Tetramethoxypropane was three-level scale. The subjects’ socioeconomic character- used as standard, and the results were expressed as istics were poor to middle class as judged by family TBARS (nmol) per milliliter of plasma.
income, with 26 out of 30 ADHD and 25 out of 29 NCsin the later category.
2.2. Supplementation with flax oil and antioxidants The data analysis was done using Microsoft Excel and SPSS. Students pair t test was applied for comparison of Flax oil supplementation corresponding to 200 mg Pre- and post-supplementation hyperactivity scores ALA content along with 25 mg Vitamin C twice a day was given for 3 months as per the assigned dose. Duringsupplementation, patients were asked to visit every 15days to collect the supplements and check up by pediatrician. No other mode of treatment like behavior-al therapy or psychostimulant medication was given to Consecutive 30 ADHD children attending the clinic these children. A placebo group was not included; were recruited in the supplementation study. Boys instead, the pre- and post-supplementation measures outnumbered girls with male to female ratio of 3:1.
within the subjects were used to assess the change in the Average age of the boys was 7 years where as girls psychopathology with parallel changes in the RBC average age was found to be 8.5 years. Majority of the membrane EPUFA and plasma peroxides.
children belonged to middle socioeconomic class. Height K. Joshi et al. / Prostaglandins, Leukotrienes and Essential Fatty Acids 74 (2006) 17–21 and weight of all ADHD children was within normal children. While SFA, OA and LA remained unaltered limits for their age. One of the ADHD children was low post-supplementation; there was a significant increase in birth weight baby and only two of them had perinatal the levels of EPA and DHA. AA level was found to be problems such as respiratory distress and jaundice.
lower in post-supplementation. Plasma TBARs were Except three cases there was no positive history of higher in post-supplementation group as compared to demographic characteristics of the subjects.
The difference in pre- and post-supplementation Except LA, pre-supplementation ADHD patients scores is found to be highly significant with Po0:001 (Pre-ADHD) had significantly lower RBC membrane ). Individual scores for Inattention, Impulsivity, lipidome levels as compared to normal controls (NC).
Restlessness and Self-Control reduced significantly post- Distribution of fatty acids was compared in RBC supplementation. SI and I scores constituting RPS were membranes pre- and post-supplementation in ADHD found to be significantly decreasing with Po0:05 inpost-supplementation group.
Table 1Demographic characteristics of study subjects The diagnosis and management of children with ADHD remains a challenge Several studies on NC: normal controls, ADHD: Attention Deficit Hyperactivity micronutrient supplementations including EFAs have shown ambiguous results and further investigations are Table 2Effect of flax oil with antioxidant supplementation on distribution of membrane fatty acids in ADHD patients (ADHD-Pre, pre-supplementationand ADHD-Post, post-supplementation) compared to normal controls (NC) Values are expressed as mean7SD. The fatty acids are expressed as percentage of total major FA. SFA—total saturated fatty acids, OA—oleic acid,LA—linoleic acid, AA—arachidonic acid, EPA—eicosapentanoic acid, DHA—docosahexaenoic acid, TBARS—thiobarbituric acid-reactivesubstances, total major fatty acids—SFA+OA+LA+AA+EPA+DHA.
Table 3Effect of flax oil with antioxidant supplementation on hyperactivity scores of ADHD patients (ADHD-Pre, pre-supplementation and ADHD-Post,post-supplementation) HS—total hyperactivity score, SC—self-control, PS—psycosomatic, R—restlessness, In—inattention, Im—impulsivity, SI—social problems, I—learning problems.
Po0:001 highly significant.
Po0:05 significant.
K. Joshi et al. / Prostaglandins, Leukotrienes and Essential Fatty Acids 74 (2006) 17–21 recommended. This is the first study to show that enhances lipid peroxidation in the target membranes supplementation with flax oil-based o-3 precursors in where greater amounts of n-3 fatty acids are incorpo- combination with antioxidants is effective in signifi- rated, thereby increasing the peroxidizability .
cantly improving symptoms of ADHD such as impul- May be concentration of antioxidants higher than the sivity, restlessness, inattention and self-control. Pre- and one presently used in combination with flax oil would post-supplementation hyperactivity scores showed sta- help in reducing lipid peroxidation.
tistically significant improvement.
Comparison of pre- and post-supplementation scores Boys with ADHD outnumbered girls in consistence demonstrates significant reduction in hyperactivity with earlier epidemiological and cross-sectional studies.
scores. The largest drop was 50 score points and in Substantial research has been done to find out etiological three cases the score was greater than before showing factors related to ADHD; however, a single cause is not that no intervention can be full proof. All the symptoms attributable for development of ADHD. ADHD subjects like impulsivity, restlessness, inattention, self-control, in this study had one or more of the conditions such as psychosomatic problems and learning problems showed low birth weight, positive history of consanguineous highly significant improvement. Social problems and marriage or perinatal problems; however, we could not learning problems together constituted-related problems find one common etiological factor causing ADHD.
score also dropped significantly. There is considerable As established by number of studies, contribution of evidence that polyunsaturated fatty acid supplementa- deficiencies or imbalances in certain highly unsaturated tion brought about improvement in educational and fatty acids in ADHD is upfront. Nevertheless, definitive behavioral problems among children with developmen- evidence of a causal contribution can only come from tal coordination disorder and reduction in ADHD- intervention studies in the form of randomized, double- related symptoms in children with specific learning difficulties Social problems are indirectly taken Very few reports on fish oil-based o-3 supplementa- care of when there is improvement in ADHD symptoms.
tion studies on ADHD children have demonstrated All the children enrolled in the study completed the improvement in ADHD symptoms like hyperactivity, supplementation course with no dropouts. Supplemen- anxiety and learning difficulty, etc In our study we tation was well accepted by children giving good have used flax oil-based supplementation, which is rich in ALA. ALA is a precursor fatty acid and with Although the results of this study are encouraging, the elongation and unsaturation gets converted to DHA.
limitation of the trial was a lack of placebo group. We There is enough evidence regarding the ability to did not include a placebo group and instead used pre- convert precursor ALA to DHA in children which and post-measures within subjects. Even though the formed logical base for our supplementation studies.
placebo has always treatment effects in psychiatric Pronounced influence of supplementation on mem- disorders, we felt that with N ¼ 30 number of patients, brane lipids of erythrocytes was revealed by significant within subjects measures should provide a significant increase in EPA and DHA. EPA as compared to DHA data. More-over, placebo effects generally do not last at is found to be beneficial in rectifying DHA deficiency very extended periods of time, such as in our study.
while keeping the peroxidation levels low. Response of In conclusion, flax oil-based emulsion could be a EPA supplementation may be related to its function as useful adjunct for effective therapy of ADHD and prostaglandin precursor and long-term effects may be further studies with placebo-controlled clinical trial on related to its conversion to DHA and subsequent large number of patients with longer duration of incorporation in membrane phospholipids . Our study has shown significantly higher levels of EPA aswell as DHA in RBC membranes in post-supplementa-tion group supporting use of ALA for effectively improving membrane EPA and DHA status.
As expected, the AA level lowered down post- supplementation owing to the D (6)-desaturase, tilt LiTaka Pharmaceuticals for supply of Flax oil emulsion.
towards DHA in presence of higher ALA: LA ratio We acknowledge Ms. Anvita Kale, IRSHA for her help The AA content was higher in infants who received the in fatty acid analysis on GC and Mr. Ashok Vairag for lowest ALA intake . Similarly in guinea pigs, dietary collection and transport of blood samples.
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