Can the Ketogenic Diet Help Patients with ADHD?

What is ADHD?

Attention deficit hyperactivity disorder (ADHD) is one of the most frequently diagnosed neurobehavioral disorders in childhood. The rates are variable worldwide ranging from 1% to as high as 20% in school-aged children ( 1).

ADHD is a disease which affects the brain and behaviour of both children and adults. It is characterised by extensive and impairing symptoms of inattention, hyperactivity and impulsivity ( 1).

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The Exact Cause of ADHD is Unknown

Both genetic and environmental factors are known to play a role in developing ADHD. Genetically, studies have shown the involvement of genes related to the receptors and transporters of dopamine and serotonin ( 2). Proposed environmental causes include infections, exposure to lead and other toxins, as well as nutritional/lifestyle factors and psychosocial adversities ( 3).

ADHD carries a high rate of comorbid psychiatric problems such as oppositional defiant disorder, conduct disorder and mood and anxiety disorders ( 4). If left untreated, the social and societal costs are considerable including, academic and occupational underachievement, difficulties in personal relationships and social problems ( 4).

What is the Standard Treatment Procedure for ADHD?

The current treatment available today can range from behavioural interventions to prescription medications. Psychotherapy and behaviour therapy are key therapeutic treatment options for ADHD.

The primary medications that are used include psychostimulants (such as Adderall and Ritalin) and non-stimulants (such as Strattera). However, not all children with ADHD will benefit from the standard pharmaceutical treatment. Some can experience common side effects such as headaches and nausea, and the long-term side effects are still not fully understood ( 5).

Can a Diet Help Manage ADHD?

Since the standard pharmaceutical treatment may not be suitable for all patients, dietary effects and changes have therefore long been investigated as a way to help alleviate the symptoms of ADHD ( 6); especially in those who are non-responsive to medications or suffering from side-effects.

The type of dietary changes which have been studied include sugar-restricted, additive/preservative-free, elimination and fatty acid supplementation (7).

One nutritional intervention which has gained in popularity and research focus over the past few years is that of the ketogenic diet.

Can the Ketogenic Diet Play a Treatment Role in ADHD?

The ketogenic diet has long had a place in neurology, with its first use in epilepsy in the 1920s ( 8). Children with epilepsy often display symptoms of ADHD, and children with ADHD have a high frequency of epileptiform discharges in EEGs ( 9).

Children with intractable epilepsy have reported a reduction in epileptiform discharges after 1 month of ketogenic diet treatment; with improvements in neurobehavioral development being shown (10).

When it comes to ADHD, currently, there has been very few studies examining the effects of the ketogenic diet in humans. A 6-month prospective, randomized, double-blinded placebo-controlled, crossover dietary trial compared the effects of the ketogenic diet vs the Standard American Diet in 21 dogs with combined ADHD and idiopathic epilepsy (11).

The results showed significant improvements in the ADHD-related behaviour with the ketogenic diet vs control. ADHD in dogs can manifest as inattention, excitability and impulsivity, all of which has been linked to the disorder in humans ( 1). Although the mechanism is unknown, the authors hypothesised that the changes of energy metabolism in the brain may contribute to the behavioural changes.

Despite the lack of direct studies looking at ADHD in children, the improvements in attention is a well-known effect of the ketogenic diet ( 12,  13).

Other studies have gone onto examine the direct impact of the ketogenic diet on cognition, mood and behaviour in children with epilepsy. Investigators of one study placed 15 children (with epilepsy) on a ketogenic diet for 6 months ( 14). The results showed no indication that the ketogenic diet has a negative impact on social adaptation, with a small trend towards improved cognition being displayed.

In a randomised controlled trial of 50 patients, one group of children were placed on a ketogenic diet and the other on a standard of care diet ( 15). Those in the ketogenic diet group reported lower levels of anxious and mood disturbed behaviours and were rated as more productive. Cognition was also reported to improve in children following the ketogenic diet.

What Does a Ketogenic for ADHD Look Like?

The ketogenic diet is a diet that is generally higher in fat, lower in carbohydrates with a moderate protein level. The exact make-up of a ketogenic diet can vary depending on the therapeutic area that it is being used for. For example, the type of ketogenic diet used in patients with epilepsy will be different from the type used in patients with diabetes.

Research that has been carried out in other neurological disorders have utilized a classical ketogenic diet, a medium-chain triglyceride diet and even a modified Atkins diet ( 16). Due to the limited number of studies conducted in humans, it is not possible to conclude the exact type of the ketogenic diet that would benefit a child and/or adult with ADHD.

There is however, a large number of clinical trials that have looked at different ketogenic dietary approaches for use within epilepsy (17). With the close links between epilepsy and ADHD, following a ketogenic dietary approach that has been used within epilepsy may be of benefit.

Can the keto diet help patients with ADHD? Due to the strong links between ADHD and epileptic symptoms, following dietary approaches similar to those observed in the epilepsy research may be of benefit.

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