Although attention deficit is a very common disease especially in childhood, it is a disease that usually progresses with hyperactivity disorder. Attention deficit is a disorder that compels children in many areas, from their social life to their quality of life. Children with attention deficit disorder experience problems such as learning disorders, depression, internalizing, and behavioral deterioration, and it is very important to evaluate these behaviors. During the treatment process, attention should not be directed only to the symptoms of lack of attention;
Disease Symptoms in Children with Attention Deficit
Attention deficit usually continues with hyperactivity disorder, and the disease begins to show symptoms before the age of 7 in children (Koca & Altuntaş, 2020). These symptoms are not suitable for normal development and continue as age-appropriate mobility, impulsivity, and lack of attention span (Koca & Altuntaş, 2020).
Children with attention deficit disorder have some symptom criteria. These symptom criteria are called DSM-IV criteria (Öner et al., 2003). Inattention symptoms must persist and be followed for at least six months. These symptoms are given below (Deniz, 2008).
• Often fails to pay attention to details, makes careless mistakes in homework or activities.
• He gets distracted in the tasks he has taken or the games he plays.
• Often does not seem to listen when spoken to.
• Generally avoids tasks that require mental effort and does not like and does not want to do these tasks.
• Often loses things for events or tasks. (Toys, pencil, book, school assignments)
• Often does not follow directions and cannot complete schoolwork and chores.
• He is immediately distracted by external stimuli.
• Often experiences forgetfulness (Deniz, 2008).
Nutritional Therapy in Attention Deficit Disease
According to studies for ADHD, the number of children diagnosed with ADHD has increased over the years, with an upward trend, hence the need for effective non-medical interventions to reduce symptomology (Reddy et al., 2018). Medication is also used for children with ADHD, but drug therapy may not be beneficial in all children and may cause concern about the side effects of drugs when it is considered to be used for a long time. Therefore, it is more appropriate to apply diet therapy to reduce symptoms. (Heilskov Rytter et al., 2015). Nutritional status in ADHD patients tends to worsen with long-term treatment due to pharmacological drugs, suggesting that it is necessary to know the dietary intake of these patients during treatment (Durá-Travé and Gallinas-Victoriano, 2014). Pharmacological treatment may be beneficial in ADHD, but many affected individuals continue to have difficulties in cognitive functions despite medical treatment, and up to 30% do not respond to pharmacological treatment (Bikic et al., 2015). Inadequate medical compliance and the long-term effects of treatment make it necessary to explore non-pharmacological and complementary therapies for ADHD. Identifying health-related behavioral risk factors, including diet quality, physical development, and sedentary activities in ADHD, is very important for improving cognitive health (Wu et al., 2016). Dietary patterns of calorie and food intake should be evaluated in patients diagnosed with ADHD, and nutritional intervention strategies should be designed for these patients (Durá-Travé and Gallinas-Victoriano, 2014).
An unhealthy diet pattern characterized as a diet low in whole grains, fish, fruits, and vegetables but high in sugar, salt, and saturated and total fat in the diet of children with ADHD has been associated with increased ADHD symptoms (Wu et al., 2016) . In children with attention deficit and hyperactivity disorder, vegetable proteins such as soy, quinoa and beans provide benefits in blood sugar control and meat products in terms of avoidance of chemical and hormone additives (Burstedde et al., 2010). Various diets are recommended to reduce attention deficit symptoms. According to these diets, food products without sugar restriction, additives and preservatives should be used and fatty acid supplements should be found (Millichap and Yee, 2012). Considering children with ADHD, it would be more appropriate to apply diet practices in two ways. The first is to follow an elimination diet, and the second is to interfere with certain foods that increase harmful food intake (Heilskov Rytter et al., 2015).
The elimination diet was originally used to treat food allergies (Ly et al., 2017). It is a diet model that is decided by evaluating the condition (Molina-Infante et al., 2014). Elimination diets vary in different ways according to the frequency and the eliminated food (Ly et al., 2017). According to the elimination diet, some foods are removed from the diet and the situation is evaluated (Heilskov Rytter et al., 2015).
Children with ADHD may show behavioral changes when they are exposed to certain foodstuffs, these are artificial food colorings, additives and sugars (Heilskov Rytter et al., 2015). According to the elimination diet, refined carbohydrates, sugars, foods containing additives and processed foods should be completely excluded from the diet (Burstedde et al., 2010). Diets that exclude food additives and oligoantigentic diets are applied in ADHD (Ly et al., 2017). Organic fruits, vegetables and meat of free-range animals should be consumed as much as possible in attention deficit and hyperactivity disorder (Burstedde et al., 2010).
Artificial Food Dyes and Other Additives
Attention deficit in children is a problem that arises with the combination of factors such as mental problems, genetic transmission, environmental factors and nutrition, and the most important factors are environmental factors and nutrition (Büyükdere and Ayaz, 2016). It has been observed that children with ADHD show hypersensitivity to additives and cause atomic symptoms (Burstedde et al., 2010).
Especially in school-age children, it is seen that the symptoms are significantly reduced when a food diet without additives and colorants is made. According to studies, it has been reported that hyperactivity disorder is caused by the consumption of some nutrients and food additives (Büyükdere and Ayaz, 2016).
Sugar and Artificial Sweeteners
Excessive consumption of refined carbohydrates and sugar in children with attention deficit and hyperactivity disorder may negatively affect learning ability, and there are studies showing that there is a direct link in increasing aggressive and restless behaviors in children (Burstedde et al., 2010). Lifestyle behaviors such as nutritional quality, lack of physical activity and inactivity have been examined, and various studies have shown that unhealthy eating models also increase the risk of ADHD (Wu et al., 2016). Artificial food dyes, colours, sweeteners, fruits and vegetables containing natural salicylates should be excluded from the diet (Heilskov Rytter et al., 2015). If positive results are observed on hyperactivity symptoms by removing these foods from the diet, this diet should be continued (Heilskov Rytter et al., 2015).
Few Foods Diet
A few foods diet is a type of strict diet that lasts 2-4 weeks, including foods with very low allergen effects (Şanlıer, 2020). It is one of the dietary approaches applied for attention deficit and hyperactivity disorder and is referred to as a few food approaches, in fact, it is a restricted elimination diet. In a study, it was revealed that a few food diets showed improvement towards 50% improvement in children (Burstedde et al., 2010).
If we look at the expansion of GAPS, it is a bowel and psychology syndrome and is a natural treatment method (Çıkıllı et al, 2019). The GAPS diet is a diet applied to eliminate the toxic fog structure on the brain and to run the brain as it should (Çıkıllı et al, 2019). In this diet, it is aimed to purify the person from toxins (Çıkıllı et al, 2019). In order to cleanse the patient from toxins, it is necessary to clean and heal the digestive tract as the first way, and then to purify the rest of the body from toxins (Çıkıllı et al, 2019). The GAPS diet consists of 3 stages, the first of which is the entry diet, the second is the full GAPS diet and the exit from the GAPS diet (Çıkıllı et al, 2019).
Nutritional Principles for Children with ADHD
Previous studies on the effect of dietary factors on ADHD have shown that supplements of certain foods or nutrients (eg, omega-3 fatty acids, zinc, magnesium) should be taken and harmful foods (eg sugar) should be restricted or eliminated (Wu et al. , 2016).
According to the diet listed by PubMed, it is recommended to switch from a western diet to a healthy diet. Additive-free and oligoantigenic/elimination diets are time consuming, so the emphasis is on applying this management in selected patients only. Iron and zinc supplements should be made in patients with deficiency. In addition, omega-3 support is of great importance in treatment. In addition to all these, nutrition education should be given to parents and children on what needs to be considered in order to create a healthy diet (Millichap & Yee, 2012).
Therapeutic Dietary Interventions
Parents who were concerned about the side effects and long-term use of pharmacological treatment turned to alternative treatment methods. Complementary and alternative medicine (CAM) offers parents a variety of treatment options, including dietary changes, nutritional supplements, herbal remedies (Burstedde et al., 2010). Two different diet models have been determined for attention deficit and hyperactivity disorder. These are the ‘western’ and ‘healthy’ diet patterns. While the Western diet model is associated with the definition of attention deficit, the healthy diet model is not associated with the definition of disease. According to the Western diet model; It contains higher total fat, saturated fat, refined sugar and sodium, and is deficient in n-3 fatty acids, fiber and folate. This diet model allows the consumption of snack foods rich in fat content and causes an increase in obesity (Şanlıer, 2019). It has been studied that probiotic therapy in children with ADHD is beneficial for atopic conditions such as eczema in children and may also be useful for hypersensitivity in ADHD responses as an immune mediator (Burstedde et al., 2010).
At the same time, essential fatty acids omega 3 support, probiotic support, B group vitamins B6, B12 and B9 should be included. If mineral support is needed, iron, zinc, calcium, magnesium, selenium supplements should be applied. Probiotic supplements should be included.
Considerations in ADHD Treatment
Nutrition is very important especially for children in the developmental age, children who consume unhealthy foods such as junk food during childhood do not have the ability to show signs of hyperactivity (Burstedde et al., 2010).
As a result of the researches, it is shown that the nutrition of children with attention deficit should be given great importance. According to a study conducted in the USA, it has been shown that common allergic conditions, especially food allergy, are associated with attention deficit and hyperactivity disorder (Xu et al., 2019).
Physical activity is also very important in the treatment of attention deficit and hyperactivity disorder, exercise increases brain activity and modulates neurotransmitter systems, thus improving memory, concentration, learning and mood (Burstedde et al., 2010).
Studies on the associations between diet or food patterns and ADHD in children and adolescents have shown that unhealthy eating patterns (eg, Western, fast-food, or junk food) are associated with increased diagnosis (Wu et al., 2016). According to studies, it has been observed that food colorings do not directly cause attention deficit and hyperactivity disorder, but improve existing symptoms (Büyükdere and Ayaz, 2016). According to the Food Additives regulation in our country, there is information on food labels that ‘may have negative effects on children’s activity and attention’ (Büyükdere and Ayaz, 2016). The foods that a patient with attention deficit and hyperactivity disorder should avoid are as follows;
• All artificial colorants
• All artificial seasonings
• Sodium benzoate
• Monosodium and monopotassium glutamate
• Butyl hydroxyanisole and butyl hydroxytoluene
• All artificial sweeteners
• Hydrolyzed or modified protein (Şanlıer, 2019).
Family Considerations and Parent Education
There are many factors that cause the inattention problem experienced in childhood, but the most important are the disadvantageous home conditions and social environment in childhood (Galler et al., 2012). It also shows that some nutritional components show behavioral changes in the behavior of children with ADHD, so dietitians should advise families on nutrition. assistance and provide the necessary training. Children should be made aware of what is good for them (Şanlıer, 2019).
In order to reduce the risk of ADHD, families should include programs and interventions that promote healthy eating and active lifestyles from childhood, and as a result, it should be shown that they will help prevent the development of ADHD, reduce the public health burden associated with this cognitive disorder and alleviate health services (Wu et al. ., 2016).