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Natural Treatments for ADHD (TADH) in Sao Paulo, Brazil, for Laboratorio Great Plains

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In this presentation, given at UNIP (Campus Paraiso - Sao Paulo, SP Brazo) for the 2019 Congresso de Saude Mental (Conference on Mental Health), Dr. Cady reviewed the prevalence, inheritability, and social ramifications of ADHD (TADH in Brazil). He specifically reviewed multiple holistic interventions, including limiting "electric screen time,"good quality diet with adequate amounts of essential fatty acids and critically important trace elements, and the use of pharmacogenomic testing as well as functional, integrative medicine testing, all to better characterize logical and reeasonmable points for holistic intervention.

This presentation was simultaneously translated into Portugue for the attendees, but unfortunately the slides were not available in translated form.

For further information in Brazil on this topic, or to order a video/audio recording of the conference (in Portuguese),contact Luiz Dias of Laboratorio Great Plains in Brazil.

Veröffentlicht in: Gesundheit & Medizin
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Natural Treatments for ADHD (TADH) in Sao Paulo, Brazil, for Laboratorio Great Plains

  1. 1. Louis B. Cady, MD, FAPA – CEO & Founder – Cady Wellness InstituteLouis B. Cady, MD, FAPA – CEO & Founder – Cady Wellness Institute Adjunct Clinical Lecturer – Indiana University School of Medicine Department of Psychiatry Functional & Integrative Neuropsychiatry – Evansville, Indiana The Natural Treatment of ADHD: New Hope and New Directions For Laboratorio Great Plains – April 13, 2019 Sao Paulo, Brazil
  2. 2. Prevalence: how much, and “why so much”?
  3. 3. Increased methylphenidate usage for attention deficit disorder in the 1990’s. Safer DJ et al. Pediatrics. 1996 Dec; 98(6 Pt 1):1084-8} • 2.5 X increase in MPH tx between 1990 and 1995 – 2.8% (1.5 million) US youths aged 5-18 received this medication in mid-1995 • “The increase in methylphenidate…appears largely related to – an increased duration of treatment; – More girls, adolescents and inattentive youths on the medication – And a recent improved public image of medication treatment.”
  4. 4. ADHD Prevalence in Brazilian children • 1,013 students aged 12 – 14 years at 64 state schools tested using a screening instrument. – 5.8% met diagnostic criteria for ADHD – ”affected youths are at high risk for impairment and dysfunction in multiple domains.” • Rhode LA et al. ( Drs. Zimmermann, Schmitz, Martins, and Tamontina were residents in Child & Adolescent Psychiatry at Federal University of Rio Gramnde do Sul, Brazil.) Journal of the American Academy of Child & Adolescent Psychiatry June 1999, volume 38, issue 6, pages 716-722.
  5. 5. ADHD and Mental Health Status in Brazilian school-age children • Objectives: assess prevalence, mental health status, and risk factors. • Methods: children aged 5 – 13 years in public elementary school. • Prevalence rate was 5.1% (95% confidence interval) • Diagnosis influenced by: maternal educational status, income class, and prenatal tobacco exposure. Arruda MA, et al. J Atten Disord. 2015 Jan;19(1):11-7. doi: 10.1177/1087054712446811.
  6. 6. “ADHD is undertreated in Brazil” Mattos P et al. Revista Brasileira Psiquiatria. Sao Paulo, Dec. 2012 • Letter to the editor: • Conservative analysis of prevalence – 0.9% – 5.3% of youths and 2.5% of adults worldwide are more common estimates. • Number of doses of methylphenidate sold: – 2009: 1,413,460 boxes of methylphenidate -represents 32,986,110 pills – 2010: 1,674,372 boxes of methylphenidate - represents 40,585,870 pills FULL TEXT of the article http://www.scielo.br/scielo.php? script=sci_arttext&pid=S1516-44462012000400023&lng=en&nrm=iso&tlng=en
  7. 7. “ADHD is undertreated in Brazil” Mattos P et al. Revista Brasileira Psiquiatria. Sao Paulo, Dec. 2012, cont. • 924,732 Braziledos would be estimated to be affected, using the 0.9% prevalence. • Calculation: number of likely cases divided by number of pills required for continuous treatment. • Conclusions: – Only 16.2% in 2008, and 19.9% in 2010 who would be appropriately treated got it. • Also noted: 30% of ADHD patients do not respond to stimulants…
  8. 8. For both groups of people hearing this presentation -- • Clinicians treating patients with straight ADD/ADHD – Medications are not necessarily evil – Holistic “bio-med” interventions are more desirable. – Some interventions that patients with autism receive (and all functional testing) may ALL be relevant in terms of remediating biological symptoms exacerbating ADHD. • Clinicians treating patients with autism spectrum disorder & ADD/ADHD – Select the most disabling set of symptoms & start stabilizing them first. – Medications should be used with CAUTION and, unless absolutely necessary, not for “chemical restraint.” – EVERY biomedical intervention and diagnostic modality should be considered. (Resources: every other presentation at this Congresso).
  9. 9. 3090 citations – ADHD/Autism 3/3/2019
  10. 10. The recent literature • Prenatal exposure to substances resulted in more mental health symptoms assoc. with ADHD and ASD, compared to controls. – Sandtorv LB et al. Subst Abuse. 2018 Mar 22;12:1178221818765773. doi: 10.1177/1178221818765773. eCollection 2018. • Use of augmented reality smartglasses – the Empowered Brain system – a behavioral and social communication aid for child, adolescents, and young aduts with ASD and high ADHD symptoms. The study showed initial evidence of the potential of this system to “reduce ADHD related symptoms… with ASD.” – Vahabzadeh A et al. JMIR Ment Health. 2018 Mar 24;5(2):e25. doi: 10.2196/mental.9631 • Children with both ASD and ADHD have an increased risk of anxiety and mood disorders. Physicians who care for children with ASD should be aware of the coexistence of these treatable conditions. – Gordon-Lipken E et al. Pediatrics. 2018 Apr;141(4). pii: e20171377. doi: 10.1542/peds.2017-1377
  11. 11. www.billfoster.com - Reviving American Manufacturing, accessed 1 27 2014www.billfoster.com - Reviving American Manufacturing, accessed 1 27 2014
  12. 12. Forbes Magazine – Feb 19, 2016
  13. 13. http://www.scdigest.com/assets/newsViews/08-06-12-2.php accessed 01 27 2014http://www.scdigest.com/assets/newsViews/08-06-12-2.php accessed 01 27 2014
  14. 14. Ordinary people are losing their jobs too….
  15. 15. Jan. 21, 2018 USA TODAY
  16. 16. Genetic etiologies • Genes most commonly associated with ADHD involve dopamine. – Faraone SV, Perlis RH, Doyle AE, et al. Molecular genetics of attention- deficit/hyperactivity disorder. Biol Psychiatry. 2005;57:1313-1323. • PET studies show excess DAT in presynaptic neuron (15% higher than in controls) – Spencer TJ, Biederman J, Ciccone PE, et al. PET study examining pharmacokinetics, detection and likeability, and dopamine transporter receptor occupancy of short- and long-acting oral methylphenidate. Am J Psychiatry. 2006;163(3):387-395.
  17. 17. Genetic tendencies in ADHD
  18. 18. Faraone SV et al. Biol Psychiatry 2005 June 1;57(11):1313- 1323. Graphic from CNS Spectr. 2007;12:4 (Suppl 6): 6- 7
  19. 19. Integrated: how to avoid over-reliance on meds • Holistic evaluation, treatment, and supplementation! • Smart prescribing! • School: – Excellent working relationships with school – Good teaching • HOME: – Diminish “electronic screens” effect – Good home discipline – Good sleep/wake schedules – Good diet AND NUTRITION – Adequate exercise • Parent training: parenting, stress tips
  20. 20. What the peer-reviewed literature says • Internet game playing was associated with lower white matter density in brain regions that are involved in decision-making, behavioral inhibition and emotional regulation. • Structural brain imaging studies showed alterations in the volume of the ventral striatum that is an important part of the brain's reward mechanisms. • Videogame playing was associated with dopamine release similar in magnitude to those of drugs of abuse and lower dopamine transporter and dopamine receptor D2 occupancy indicating sub- sensitivity of dopamine reward mechanisms. Weinstein A, et al. Neurosci Biobehav Res. April 2017
  21. 21. Death by video game • 2005 – S. Korean, addicted to StarCraft – lost job, girlfriend. Spent all money at an internet. 14-18 hours at a time. – One day, went 50 hours nonstop, collapsed, and died from exhaustion and dehydration. • 2015 – Taiwan man – dead from cardiac failure after a three-day online gaming binge. • 2007 – 15 year old boy shot both parents over his video game (Halo 3) being confiscated • 17 year old Philippine teen murdered his 68 year old GM for interrupting his game in an internet café.
  22. 22. New diagnostic codes and treatment facilities • ICD-10 Diagnostic codes: – Y93.C1 – keyboard playing video games – Y93.C2 – video games including cell phones, communication devices (tablets) and other interactive devices. • Treatment facilities – McLean Hospital in Belmont MA has set up Computer Addiction Services. – Chinese Government operates several clinics to treat those suffering from overuse of online games, chatting, and web surfing. “Electrical shock treatments” used.
  23. 23. Di Chiara, G et al. Neuropharmacology, 47(1), Supl 1, 2004:227-241 • Addictive drugs increase extracellular dopamine in nucleus accumbens. • Brain imaging studies: have demonstrated correlation between psychostimulant induced increase of extracellular CA and self-reported measures of liking and “high”(euphoria).
  24. 24. Emergence of diagnoses of game playing pathology • “Internet gaming disorder” – Now listed in DSM5 research appendix as a “condition for further study.” • “GAMING DISORDER” – World Health Organization, 2018 – Applies on online and offline gaming.
  25. 25. My Previous Notion of Therapeutic Options
  26. 26. Do stimulant drugs work in children with ASD and ADHD? • Meta-analysis of four cross-over studies, with 113 children ages 5 – 13 (83% boys) • “We found that short-term use of methylphenidate might improve symptoms of hyperactivity and possibly inattention in children with ASD who are tolerant of the medication, although the low quality of evidence means that we cannot be certain of the true magnitude of any effect. There was no evidence that methylphenidate has a negative impact on the core symptoms of ASD, or that it improves social interaction, stereotypical behaviours, or overall ASD.” – Sturman N et al. Methylphenidate of children and adolescents with autism spectrum disorder. Cochrane Database Syst Rev. 2017 Nov 21;11:CD011144. doi: 10.1002/14651858.CD011144.pub2.
  27. 27. www.pubmed.gov www.google.com www.scholar.google.com
  28. 28. • The present study found that 53 subjects with ADHD had significantly lower concentrations of key fatty acids in the plasma polar lipids (20:4n-6, 20:5n-3, and 22:6n-3) and in red blood cell total lipids (20:4n-6 and 22:4n-6) than did the 43 control subjects • “…but the precise reason for lower fatty acid concentrations in some children with ADHD is not clear.” • The present study found that 53 subjects with ADHD had significantly lower concentrations of key fatty acids in the plasma polar lipids (20:4n-6, 20:5n-3, and 22:6n-3) and in red blood cell total lipids (20:4n-6 and 22:4n-6) than did the 43 control subjects • “…but the precise reason for lower fatty acid concentrations in some children with ADHD is not clear.”
  29. 29. • “We argue that a change in the ratio of n-6/n-3, especially during early life, may induce developmental changes in brain connectivity, synaptogenesis, cognition and behavior that are directly related to ASD.” • “We argue that a change in the ratio of n-6/n-3, especially during early life, may induce developmental changes in brain connectivity, synaptogenesis, cognition and behavior that are directly related to ASD.”
  30. 30. • Western diet: omega 3 fatty acid deficiency and increased fructose intake. • “Both promote brain insulin resistance and increase the vulnerability to cognitive dysfunction.” • “Multiple cognitive domains are affected by metabolic syndrome in adults and in obese adolescents, with volume losses in the hippocampus and frontal lobe, affecting executive function.” • Western diet: omega 3 fatty acid deficiency and increased fructose intake. • “Both promote brain insulin resistance and increase the vulnerability to cognitive dysfunction.” • “Multiple cognitive domains are affected by metabolic syndrome in adults and in obese adolescents, with volume losses in the hippocampus and frontal lobe, affecting executive function.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775234/
  31. 31. • In Adults with ADHD: • DECREASED DHA, AA, and DHGLA • “We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.HGLA were lower than controls.” • In Adults with ADHD: • DECREASED DHA, AA, and DHGLA • “We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.HGLA were lower than controls.”
  32. 32. Reduced Levels of Omega-3 Fatty Acids are Associated with ADHD Antalis et al., Prostaglandins Leukot Essent Fatty Acids, 2006. 75(4-5): p. 299-308.
  33. 33. This summary demonstrates that a deficiency in brain PUFAs will lead to cognitive deficits, while supplementation of PUFAs can rehabilitate cognitive deficits, as manifested in attention deficit hyperactivity disorder, stress/anxiety, and aging. This summary demonstrates that a deficiency in brain PUFAs will lead to cognitive deficits, while supplementation of PUFAs can rehabilitate cognitive deficits, as manifested in attention deficit hyperactivity disorder, stress/anxiety, and aging.
  34. 34. PUFA’s as cognitive enhancers • Low dose PUFA supplementation study • French community dwellers aged 70 or over reporting subjective memory complaints; NOT DEMENTED. • PUFA – 800 mg DHA / 225 mg EPA • Less cognitive decline over 36 months. Hooper C et al. Cognitive changes with omega-3 polyunsaturated fatty acids in non-demented older adults with low omega-3 index. J Nutr Health Aging. 2017; 21(9):968- 993
  35. 35. PUFA + Methylphenidate (Ritalin) • 40 children with ADHD in study, 2014. – 82.5% boys, 17.5% girls • Two groups: – MPH + PUFA – MPH + placebo • Response to treatment (reduction of at least 25% of signs) – MPH + Placebo 60% – MPH + PUFA 90% Moghaddam MF et al. Effectiveness of methylphenidate and PUFA for the treatment of patients with ADHD” a double-blinded randomized clinical trial. Electron Physician. 2017 May25;9(5):4412-4418
  36. 36. HOW TO DO IT • Key principles of essential fatty acid supplementation are: – Do not use large doses of a generic omega 6 or omega 3 fish oil and presume that you are going to get adequate amounts of EPA and DHA out the bottom of the pathways. – The only two sources of fish oil high in PUFA’s that we get are from eating fish or taking fish oil. Period. If we don’t eat fish, we should probably be on fish oil. – We DO have the ability to synthesize the critical PUFA’s, including EPA and DHA, from precursors, but in order to do so, we must have adequate amounts of the critical trace minerals.
  37. 37. NOTE: The essential elements portion of this test include: •Elemental lithium •Iron •Magnesium •Zinc •copper NOTE: The essential elements portion of this test include: •Elemental lithium •Iron •Magnesium •Zinc •copper
  38. 38. IRON - Most common of all nutrient deficiencies in U.S. school-aged children Murray & Pizzorno. Encyclopedia of Natural medicine. Rocklin, CA: Prima Publishing; 1998. • Deficiency associated with: markedly decreased attentiveness, narrower attention span, decreased persistence, and lowered activity level – all of which respond positively to supplementation. • Kidd. ADHD in Children: Rationale for Its Integrative Management. Alt Med Review 2000; 5(5):402-427. • 30% improvement in Conners ADHD Rating Scale following iron supplementation [(Ferrocal), 5 mg/kg/day for 30 days] in one uncontrolled Israeli study of boys. • Sever et al. Iron treatment in children with attention deficit hyperactivity disorder. A preliminary report. Neuropyshcobiology 1997;35:178-180. 0 5 10 15 20 25 30 35 40 45 serum ferritin Conners before after Significant increase in serum ferritin levels (from 25.9 +/- 9.2 to 44.6 +/- 18 ng/ml) and a significant decrease on the parents' Connors Rating Scale scores (from 17.6 +/- 4.5 to 12.7 +/- 5.4).
  39. 39. Iron & ADHD – 2018 data • Meta-analysis to compare ADHD symptoms and iron levels/iron deficiency (ID) – 17 articles met search criteria. • “Peripheral serum ferritin levels were significantly lower in ADHD children, but with no significant difference in iron or transferrin levels. (!!!) • “Our results suggest that ADHD is associated with lower serum ferritin levels and ID (iron deficiency).” Tseng PT et al. Peripheral iron levels in children with attention-deficit hyperactivity disorder: a systematic review and meta-analysis. Sci Rep. 2018, Jan 15;8(1):788.
  40. 40. Zinc link --- and friends • Psychiatr Pol 1994 May-Jun;28(3):345-53 [Deficiency of certain trace elements in children with hyperactivity] [Article in Polish]Kozielec T, Starobrat-Hermelin B, Kotkowiak L. Zakladu Medycyny Rodzinnej Pomorskiej Akademii Medycznej. • The magnesium, zinc, copper, iron and calcium level of plasma, erythrocytes, urine and hair in 50 children aged from 4 to 13 years with hyperactivity, were examined by AAS. The average concentration of all trace elements was lower compared with the control group--healthy children from Szczecin. The highest deficit was noted in hair. • Our results show that it is necessary to supplement trace elements in children with hyperactivity.
  41. 41. Della Lucia CM et al. Nutrients. 2016 May 14;8(5).
  42. 42. Della Lucia CM et al. Nutrients. 2016 May 14;8(5). Methods and results • 99 children 2-6 years; 42.6% male. • 2 preschools – one with UltraRice® (UR®) and one with polished (unfortified) Rice. • The fortified rice improved: level of Zinc, Thiamine, Folic acid, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration. • Inadequacies of thiamine, folic acid and IRON were lower among the test preschool.
  43. 43. Assessment of magnesium levels in children with attention deficit hyperactivity disorder (ADHD) • 116 children with ADHD • Magnesium deficiency was found in 95 per cent of those examined: – most frequently in hair (77.6 per cent) – in red blood cells (58.6 per cent) – and in blood serum (33.6 per cent) • CONCLUSIONS: magnesium deficiency in children with ADHD occurs more frequently than in healthy children. Analysis of the material indicated the correlation between levels of magnesium and the quotient of development to freedom from distractibility. Kozielec T, Starobrat-Hermelin B. Magnes Res 1997 Jun;10(2):143-8
  44. 44. The effects of magnesium physiological supplementation on hyperactivity in children with ADHD. Positive response to magnesium oral loading test. • Examined: – Treatment group: 50 hyperactive children, ages 7-12 years, per DSM IV criteria for ADHD. – Control group- 25 children – Treated group – 25 children 200 mg Magnesium per day. • Results: – “an increase in magnesium contents in hair and a significant decrease of hyperactivity of those examined has been achieved, compared to their clinical state before supplementation.” Starobrat-Hermelin BN, et al. Magnesium Research. 1997 Jun;10(2):149-56
  45. 45. Putting it all together with new technology… One illustrative cases
  46. 46. The adorable rager – parents concerned; interested in natural treatment • 7 years of age • Generally sweet • Unpredictable rages • Assaultive • Intermittently totally unmanageable
  47. 47. Google: L-methylfolate: a vitamin for your monoamines. Stahl
  48. 48. THEREFORE: informed treatment decisions • Diet – eliminate dairy and wheat • L-Methylfolate support to bypass MTHFR • Vayarin for membrane stabilization • 5HTP to supply more raw material for serotonin synthesis • Lithium – 10 drops = 0.5 mg
  49. 49. Crocus sativus (saffron) vs. methylphenidate in treatment of children with ADHD • 6 week randomized double-blind study, n= 54 (children 6 – 17 years), with DSM5 diagnosis of ADHD. • RX: – 20 – 30 mg per day methylphenidate – 20 – 30 mg saffron capsules. “Short term therapy with saffron capsule showed the same efficacy compared with methylphenidate.” Baziar S et al. J Child Adolescent Psychopharmacology. 2019 Feb 11.
  50. 50. Treatment of side effects: • Folic acid appears to stimulate appetite in ADHD children treated with MPH • Randomized, double blind clinical trial with 70 outpatients, ages 6 – 1 2 years. – Group 1 – 1 mg/kg MPH plus 5 mg folic acid/day – Group 2 – 1 mg/kg MPH plus placebo. • “Appetite was significantly improved in group 1” Riahi F et al. Effects of folic acid on appetite in children with attention deficit hyperactivity disorder treated with methylphenidate: a randomized double-blind clinical trial. Iran J Med Sci. 2018 Jan;43(1):9-17.
  51. 51. “Don’t think ‘either/or.’ Think ‘both/and.’ ” - Dan Burrus
  52. 52. Summary – WHAT YOU CAN DO • Get rid of/stop playing video games. Beware computer/internet addiction • Get functional medicine testing: – IgG Food Allergies, organic acid testing, hair analysis, pharmacogenomics (esp. MTHFR and COMT). Conventional (but sophisticated) labs, e.g. RBC Mg, RBC Zn, etc. B12 AND Methylmalonic acid. Ferritin. • Avoid over-reliance on medication • Holistic: – Address ANY MTHFR deficiencies. – Fish oil (good quality EPA/DHA), replace elemental deficiencies (magnesium, zinc, copper, iron), & replenish gut microbiota with probiotics – Consider low dose lithium, rhodiola (if indicated); saffron – Consider precursor loading therapy (l-phenylalanine, l-tyrosine, 5- dydroxytrptophan)
  53. 53. “There are things known and there are things unknown, and in between are the doors.” - Jim Morrison
  54. 54. Contact information: Louis B. Cady, M.D. www.cadywellness.com Office: 812-429-0772 E-mail: lcady@cadywellness.com 4727 Rosebud Lane – Suite F Interstate Office Park Newburgh, IN 47630 (USA) Link to all slides from this presentation: www.slideshare.net/lcadymd

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