Kids who lacked omega-3 EPA displayed bigger attention gains from fish oil, vs. stimulants like Ritalin
As many as six million American kids — nearly one out of 10 — suffer from attention deficit hyperactivity disorder or ADHD.
Most of the affected children are six to 17 years old, and boys are about twice as likely as girls to have ADHD.
Childhood ADHD rates rose sharply from 2003 to 2011 and seemed to decline slightly in a 2016 survey, although its methods differed from prior surveys, making comparisons unreliable.
Standard treatments include behavior modification training for parents, behavior modification techniques for ADHD patients, and stimulant drugs such as methylphenidate (Ritalin).
According to the American Academy of Pediatrics, there isn’t enough evidence to accurately judge the efficacy of mindful meditation, cognitive training for kids, diet changes, EEG biofeedback therapy, or counseling.
In contrast, judging by the mixed but generally positive clinical evidence, the omega-3s in seafood and fish oil (DHA and EPA) can benefit ADHD sufferers, while higher maternal intakes of those omega-3s during pregnancy may help prevent or ameliorate ADHD in their offspring.
Unfortunately — despite strong evidence that these factors really matter — researchers and doctors often fail to consider children’s intakes of omega-3s and omega-6s, and the dietary balance between those two families of essential fatty acids.
In addition to supporting higher intakes of seafood-source omega-3s among children and pregnant mothers, most evidence also supports reducing their intakes of omega-6 fatty acids (see Mothers’ Omega Intakes May Raise Babies’ ADHD Risk, Omega-3s' ADHD Benefits Clarified, and their links to related articles).
Those findings probably flow from the fact that the average American consumes omega-6 fats to extreme, pro-inflammatory excess, compared with their very low intake of omega-3s — an imbalance that limits the benefits of dietary omega-3s.
Today’s report concerns the results of a new clinical study, which may help identify the children most likely to benefit from omega-3 fish oil — and suggest that those children may enjoy bigger benefits from fish oil than from stimulant drugs like Ritalin.
UK-Taiwanese clinical trial pinpoints fish oils’ best ADHD prospect
The new randomized, controlled clinical trial was performed by researchers from King’s College London and Taiwan’s China Medical University (Chang JP et al. 2019).
Previous research by the same group found that children with low omega-3 blood levels are more likely to suffer more severe ADHD symptoms (Parletta N et al. 2016).
For their 12-week trial, the UK-Taiwanese team recruited 92 children with ADHD, aged six to 18 years, who were given either placebo capsules or fish oil capsules that contained 1.2 grams of omega-3 EPA.
Unlike standard fish oils, the fish oil used in this trial did not contain significant amounts of omega-3 DHA, which has shown benefit in prior ADHD studies.
The UK-Taiwanese team say that theirs was the first trial to do two things:
- Examine the effects of omega-3s in children with different blood levels of omega-3s.
- Test omega-3 EPA rather than the combined DHA and EPA found in standard fish oils.
Low omega-3 EPA levels signal that a child consumes very little seafood or fish oil. And, since fish and fish oil typically contain roughly equal amounts of EPA and DHA, a child who lacks EPA will almost certainly lack omega-3 DHA, which is more essential to brain structure and functions.
To see whether they affected a child’s response to the EPA, the researchers tested the children’s blood levels of omega-3 DHA and EPA, c-reactive protein (CRP, a marker of inflammation), and brain-derived neurotrophic factor or BDNF — a protein that protects brain cells and stimulates stronger networks among them (so-called “synaptic plasticity”), which in turn enhances a broad range of brain functions.
At the end of the 12-week trial, the children in the fish oil group who had the lowest EPA blood levels showed improvements in focused attention and vigilance.
The truly striking finding was that — among the kids with low EPA blood levels — fish oil produced substantially bigger benefits, compared with Ritalin.
Specifically, the “effect size” of improvement in attention and vigilance from omega-3 fish oil was 0.89 for attention and 0.83 for vigilance, compared with 0.22 and 0.42 for Ritalin.
The omega-3 EPA fish oil also improved attention among children also diagnosed with Oppositional Defiant Disorder (ODD), who constituted about half of the participants.
According to study co-author Jane Chang, “Our results suggest that fish oil supplements are at least as effective for attention as conventional pharmacological treatments among those children with ADHD who have omega-3 deficiency.”
Her colleague, professor Carmine Pariante, stressed two important points: “The omega-3 supplements only worked in children that had lower levels of EPA in their blood, as if the intervention was replenishing a lack of this important nutrient. For those children, fish oil supplements could be preferable to standard stimulant treatments.”
The attention and vigilance improvements didn’t appear in children with normal or high EPA blood levels. In fact, surprisingly, the EPA-only fish oil seemed to worsen their impulsivity symptoms.
Interestingly, supplemental omega-3 EPA did not raise the children’s brain levels of BDNF, nor did it reduce levels of the inflammation-marker CRP. However, the researchers noted that — unlike omega-3 DHA — EPA is not known to affect brain levels of BDNF, and that all the children started the study with relatively low levels of inflammation, making it unlikely that the supplemental EPA would lower them significantly.
(Omega-3 DHA promotes release of BDNF and the stronger, richer brain networks that result — for more on that, see Omega-3s Linked to Lower Teen Anxiety, Omega-3s Boosted Healthy Seniors' Brains, and Fish Fats Boost Brain Resilience.)
Many more American kids with ADHD would likely benefit
It’s important to note that the study took place in Taiwan, where — compared with America — diets typically feature plenty of fish.
As the researchers noted, most American and Western children with ADHD have lower average blood EPA levels than the Taiwanese children did — which strongly suggests that a bigger proportion of American kids with ADHD would benefit from fish oil.
Professor Kuan-Pin Su, Another co-author of the new clinical trial, stressed the implications of dietary differences between Taiwan and Western countries: “High blood-levels of EPA … can be achieved through a good diet with plenty of fish, which is common in some Asian countries … EPA deficiency is more common … in North America and many countries in Europe, and fish oil could therefore have more widespread [ADHD treatment] benefits [in those regions] ...”.
The researchers suggested looking for signs of omega-3 deficiency, including dry and scaly skin, eczema, and dry eyes. At-home omega-3 blood tests are readily available online and could help identify the children with ADHD most likely to benefit from supplemental fish oil.
- Cardoso HD et al. Omega-3 deficiency and neurodegeneration in the substantia nigra: Involvement of increased nitric oxide production and reduced BDNF expression. Biochim Biophys Acta. 2013 Dec 20;1840(6):1902-1912. doi: 10.1016/j.bbagen.2013.12.023. [Epub ahead of print]
- Centers for Disease Control and Prevention. Data and Statistics About ADHD. Accessed at https://www.cdc.gov/ncbddd/adhd/data.html
- Chang JP, Su KP, Mondelli V, Satyanarayanan SK, Yang HT, Chiang YJ, Chen HT, Pariante CM. High-dose eicosapentaenoic acid (EPA) improves attention and vigilance in children and adolescents with attention deficit hyperactivity disorder (ADHD) and low endogenous EPA levels. Transl Psychiatry. 2019 Nov 20;9(1):303. doi: 10.1038/s41398-019-0633-0.
- Ferreira CF, Bernardi JR, Bosa VL, Schuch I, Goldani MZ, Kapczinski F, Salum GA, Dalmaz C, Manfro GG, Silveira PP. Correlation between n-3 polyunsaturated fatty acids consumption and BDNF peripheral levels in adolescents. Lipids Health Dis. 2014 Mar 5;13:44. doi: 10.1186/1476-511X-13-44.
- Hashimoto M, Inoue T, Katakura M, Tanabe Y, Hossain S, Tsuchikura S, Shido O. Prescription n-3 fatty acids, but not eicosapentaenoic acid alone, improve reference memory-related learning ability by increasing brain-derived neurotrophic factor levels in SHR.Cg-Lepr(cp)/NDmcr rats, a metabolic syndrome model. Neurochem Res. 2013 Oct;38(10):2124-35. doi: 10.1007/s11064-013-1121-1. Epub 2013 Aug 21.
- Parletta N, Niyonsenga T, Duff J. Omega-3 and Omega-6 Polyunsaturated Fatty Acid Levels and Correlations with Symptoms in Children with Attention Deficit Hyperactivity Disorder, Autistic Spectrum Disorder and Typically Developing Controls. PLoS One. 2016 May 27;11(5):e0156432. doi: 10.1371/journal.pone.0156432. eCollection 2016.
- Wolraich ML et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019 Oct;144(4). pii: e20192528. doi: 10.1542/peds.2019-2528.