The role of diet in managing immune dysfunction and inflammatory processes that contribute to ADHD and related neurodevelopmental disorders ADHD is a neurodevelopmental disorder characterised by lack of attention, impulsiveness, and hyperactivity. Its cause is considered to be multifactorial, involving a combination of genetics, perinatal factors (e.g., low birth weight, prematurity, prenatal exposure to toxins such as alcohol and/or smoke), as well as environmental and socioeconomic factors. The immune system is a key player in gut–brain interactions, with extensive alterations in immune function known to contribute to the pathophysiology of neurodevelopmental disorders, including dysregulated inflammation, elevated levels of pro-inflammatory cytokines and altered immune cell function. In this webinar Dr Nina Bailey will describe the role of immune dysfunction and inflammatory processes linked to the pathophysiology of neurodevelopmental disorders and will provide an overview of the nutritional interventions that can help to successfully manage symptoms.

1. Immune dysfunction and inflammatory processes
in ADHD
Nina Bailey
BSc (hons) MSc PhD ANutr

2. Attention-deficit hyperactivity disorder (ADHD) is relatively common
and increasing in diagnosed frequency; recent prevalence estimates in
childhood are 8.7–10.6%
 The burden associated with childhood and adolescent ADHD
includes:
• Diminished quality of life for patients and their families
• Increased economic costs
• Increased risk for the development of long-term academic
underachievement
If ADHD is inadequately managed and continues to adulthood:
• Increased conduct disorder/violence
• Increased risk of alcohol dependence
• Increased risk of antisocial behaviour or criminality
M.L. Wolraich, R.E. McKeown, S.N. Visser,et al. The prevalence of ADHD: its diagnosis and treatment in four school districts across two States
J. Atten. Disord. (2012)

3. Hyperactivity symptoms
•Often fidgets with hands or feet or squirms in seat
•Often leaves seat in classroom or in other situations in which
remaining seated is expected
•Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
•Often has difficulty playing or engaging in leisure activities quietly
•Is often 'on the go' or often acts as if 'driven by a motor'
•Often talks excessively
Impulsivity symptoms
•Often blurts out answers before questions have been completed
•Often has difficulty awaiting turn
•Often interrupts or intrudes on others (for example, butts into
conversations or games)
Inattentive symptoms
• Does not give close attention to details or makes careless mistakes
• Has difficulty sustaining attention on tasks or play activities
• Does not seem to listen when directly spoken to
• Does not follow through on instructions and does not finish
schoolwork, chores, or duties in the workplace
• Has trouble organising tasks or activities
• Avoids, dislikes, or is reluctant to do tasks that need sustained mental
effort
• Loses things needed for tasks or activities
• Easily distracted
• Forgetful in daily activities
American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV)

4. Criteria for attention-deficit/hyperactivity disorder (ADHD) as defined by the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV)
A minimum of 6 symptoms of inattention, or a minimum of 6 symptoms of
hyperactivity–impulsivity, that have persisted for at least 6 months to a degree
that is maladaptive and inconsistent with developmental level
Based on the presenting symptom, ADHD can be divided into three
subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and
combined type
The symptoms must appear before age seven, and appear in the school
environment as well as the home

5. Factors influencing ADHD risk
A number of stressors such as maternal or foetal distress,
birth interventions, poor diet, a lack of omega-3 or an
imbalance in the ratio of omega 6 to 3 may cause the
brain to ‘glitch’ in its development

6. Maternal diet
Maternal diet and metabolic state are important factors in
determining the environment experienced during perinatal
development
Epidemiological studies and evidence from animal models provide
evidence that a mother's diet and metabolic condition are important
in programming the neural circuitry that regulates behaviour,
resulting in a persistent impact on the offspring's behaviour

7. Maternal diet
Potential mechanisms by which maternal diet and metabolic profile
influence the perinatal environment include
 placental dysfunction
 increases in circulating factors such as inflammatory cytokines,
nutrients (glucose and fatty acids) and hormones (insulin and leptin)
Maternal obesity and high-fat diet (HFD) increased the risk of developing
serious mental health and behavioural disorders including anxiety,
depression, attention deficit hyperactivity disorder and autism spectrum
disorder
The increased risk due to changes in the development of neural pathways
that regulate behaviour, including the serotonergic, dopaminergic and
melanocortinergic systems

8. Sullivan EL, Smith MS, Grove KL. 2011 Perinatal exposure to high-fat diet programs
energy balance, metabolism and behaviour in adulthood. Neuroendocrinology. 93:1-8.
Exposure to maternal
high-fat diet (HFD)
consumption programs
offspring for increased
risk of adult obesity
The role of maternal diet

9. Diet quality reflects inflammatory markers
•Dietary pattern, characterised by higher intakes of vegetables
and fruit, whole grains, fish and legumes, are generally
associated with reduced plasma concentrations of inflammatory
markers (i.e. CRP, IL-6, homocysteine, ICAM-1)
•In contrast, unhealthy ‘Western’ pattern, high in red and
processed meats, refined carbohydrate and other processed
foods are associated with increased inflammatory markers
•Diet quality also affects gut flora composition
Nettleton, J. A., L. M. Steffen, et al. (2006). "Dietary patterns are associated with biochemical markers of
inflammation and endothelial activation in the Multi-Ethnic Study of Atherosclerosis (MESA)." The American
journal of clinical nutrition 83(6): 1369-1379.

10. Beneficial functions of gut microbiota
 Defence against pathogen colonisation by nutrient competition and
production of antimicrobial substances
 Fortification of intestinal epithelial barrier and induction of secretory
immunoglobulin A synthesis to limit pathogenic bacteria penetration into
tissues
 Facilitation of nutrient absorption by metabolising indigestible dietary
compounds
 Participation in the maturation and functionality of the host immune system
by providing diverse signals for “tuning” the host immune status

11. Angela E. Vinturache, Cynthia Gyamfi-Bannerman, Joseph Hwang, Indira U. Mysorekar, Bo Jacobsson. Maternal microbiome –
A pathway to preterm birth. Seminars in Fetal and Neonatal Medicine, Volume 21, Issue 2, 2016, 94–99
Maternal microbiome from
reproductive and non-reproductive
niches play a role in regulation of the
timing of parturition
Alterations in microbial diversity in
various maternal niches impact
preterm delivery

12. The TLR4 signalling pathway culminates in activation
of the transcription factor nuclear factor-kappaB
(NFkB)
NFkB controls the expression of an array of
inflammatory cytokine genes
TLR4 agonists:
•Lipopolysaccharide (LPS)
gram negative bacteria
•Saturated fat/high fat diets
• Palmitic acid
• Stearic acid
Rocha DM, Caldas AP, Oliveira LL, Bressan J, Hermsdorff HH. Saturated fatty
acids trigger TLR4-mediated inflammatory response. Atherosclerosis. 2016
Jan;244:211-5.

13. IL-1, IL-6, TNF-α Acute Phase Proteins
C-reactive protein (CRP),
Serum amyloid A (SAA)
PLA2/COX2/LOX
NFκB
Receptor mediated pathways
(Toll like receptors [TLR], TNF-α, IL-
1, LPS, dietary factors)
Inflammation stimulus (i.e.
tissue injury, infection, heat
stress, psychological stress)
Prostaglandins
Leukotrienes
Thromboxanes
INFLAMMATION

14. •Soluble intercellular adhesion molecules (sICAMs) have important role
in modulating inflammatory diseases
•sICAM-1 is present in normal human serum, whilst elevated sICAM-1
have been found in serum from patients with cardiovascular disease,
cancer, autoimmune disease and several studies have correlated serum
levels of sICAM-1 with severity of disease
•The levels of sICAM-1 and sICAM-2 were significantly higher in ADHD
patients compared with controls
•The level of sICAM-2 was decreased significantly in group treated with
methylphenidate
Alaşehirli B, Oguz E, Gokcen C, Erbagcı AB, Orkmez M, Demiryurek AT. Relationship between soluble
intercellular adhesion molecules and attention-deficit/hyperactivity disorder. Int J Psychiatry
Med. 2015;50(2):238-47.

15. Successful human reproduction requires microbial homeostasis in the
female reproductive tract, and colonisation of the newborn with
beneficial microbes
Maternal transfer of microorganisms is possible during pregnancy and
lactation, and the mother's diet and microbiota can influence that of
her offspring
Children born by caesarean have different gut microbiota from those
born vaginally, with the latter involving exposure to the mother’s
bacteria, whereas delivery by caesarean involves exposure to skin
microbiota
Gut bacteria start to stabilise at age 1 and become ‘adult-like’ at age 3
http://www.isapp.net/Portals/0/docs/handbook%20gut%20microbes.pdf

16. http://www.tommys.org/page.aspx?pid=387
 Babies born prior to 37 weeks are considered preterm and are at increased
risk of illness, disability and death
• extremely preterm: < 28 weeks
• very preterm: from 28 to < 32 weeks
• moderate to late preterm: from 32 to < 37 weeks
 In 2012 (England and Wales):
• 7.3% of live births were preterm
• 92.7% of these preterm births occurred after 28 weeks
 Nearly 85% of all babies born prematurely will have a very low birth weight
(under 1,000g), compared to 94% of babies born under 24 weeks
 Preterm birth rates in England and Wales have remained steady (7.3% in
2009, 7.1% in 2010, 7.2% in 2011 and 7.3 in 2012)

17. O'Shea TM, Downey LC, Kuban KK. Extreme prematurity and attention deficit: epidemiology and
prevention. Front Hum Neurosci. 2013 Sep 19;7:578.
ADHD and preterm birth
Preterm infants are at increased risk for a wide range of developmental
disorders, including sensory, motor, cognitive, and other brain disorders
and the risk is highest for those infants born before 28 weeks gestation,
i.e. extremely preterm or extremely low gestational age infants

18. Causes of preterm birth
Many of the causes of these preterm births are still unknown, but it is thought that
around 25% of them may be related to a bacterial infection that comes from
somewhere in the mother’s own body, i.e. her microbiome
Case-control study :
• Vaginal, distal gut, salivary, and tooth/gum microbiomes of 49 women, were
analysed over the course of their pregnancy and for one year after
• Non-vaginal sites’ microbiomes remained relatively stable over the duration of
the pregnancy, and even for the one year after
• The vaginal microbiome did show some differences during and after pregnancy
• 15 women delivered preterm
• Significant differences in normal flora pattern found, with abundance of
Gardnerella vaginalis, and Ureaplasma, specifically, were linked to preterm birth
DiGiulio DB, Callahan BJ, McMurdie PJ, Costello EK, Lyell DJ, Robaczewska A, Sun CL, Goltsman DS, Wong RJ, Shaw G, Stevenson
DK, Holmes SP, Relman DATemporal and spatial variation of the human microbiota during pregnancy. Proc Natl Acad Sci U S .2015 Sep
1;112(35):11060-5.

19.  Maternal infection is a frequent initiator of preterm labour and is
often accompanied by a foetal systemic inflammatory response
 Foetal exposure to a strong pro-inflammatory challenge (such as
intrauterine infection) elicits a foetal inflammatory response that
contributes to both preterm delivery and brain damage in the preterm
newborn
 Pro-inflammatory cytokines such as tumour necrosis factor (TNF)-α
can affect the developing brain and blood-brain barrier; intrauterine
infection and a pro-inflammatory cytokine response are involved in
the pathogenesis of preterm brain white matter damage
Dammann O., O'Shea T. M. (2008). Cytokines and perinatal brain damage. Clin. Perinatol. 35, 643–663

20.  Pre-term and early term birth increases the risk of ADHD by degree of immaturity
 The risk for hyperactivity and attention problems appears to increase for children
who are born a month or more before their due dates and gradually rises with
each additional week of prematurity
 Babies born very early, between 23 and
28 weeks of gestation, had more than
double the risk of developing ADHD
compared with those who were carried
to term, from 39 to 41 weeks
 Those born between 35 and 36 weeks of
gestation, a much more common
circumstance, had about a 30% greater
chance of having ADHD compared with
babies that arrived on time
Gestational age, weeks OR (95% CI)
23–28 2.1 (1.4–2.7)
29–32 1.6 (1.4–1.7)
33–34 1.4 (1.2–1.7)
35–36 1.3 (1.1–1.4)
37–38 1.1 (1.1–1.2)
39–41 1
42 or more 1.0 (0.9–1.1)
Lindström K, Lindblad F, Hjern A. 2011 Preterm birth and attention-deficit/hyperactivity
disorder in schoolchildren. Paediatrics. 127:858-65.

21. S.M. O’Mahony, G. Clarke, Y.E. Borre, T.G. Dinan, J.F. Cryan Serotonin, tryptophan metabolism and the brain-gut-microbiome axis Behavioural
Brain Research, Volume 277, 2015, 32–48
The development and maturation of the gastrointestinal microbiota

22.  75 infants who were randomized to receive Lactobacillus rhamnosus or placebo during the first 6
months of life were followed up for 13 years
 Gut microbiota was assessed at the age of 3wk, 3, 6, 12, 18, 24 months, and 13 years
 The diagnoses of ADHD and Asperger syndrome by a child neurologist or psychiatrist were based
on ICD-10 diagnostic criteria
 At the age of 13 years, ADHD or AS was diagnosed in 6/35 (17.1%) children in the placebo and
none in the probiotic group (p = 0.008)
 Numbers of bifidobacterium species bacteria in faeces during the first 6 months of life was
significantly lower in affected children (p = 0.03)
 Probiotic supplementation early in life may reduce the risk of the development of
neurodevelopmental issues later in childhood
Pärtty A, Kalliomäki M, Wacklin P, Salminen S, Isolauri E.A possible link between early probiotic intervention and the risk of
neuropsychiatric disorders later in childhood: a randomized trial. Pediatr Res. 2015 Jun;77(6):823-8.
Probiotic intervention and ADHD outcomes

23. ADHD and leaky gut
 Excess inflammation damages cells and epithelium
 Undigested food particles may pass through gaps
 The immune system may react to this by
creating more inflammation
 Commonly leads to food intolerances – an immune reaction to various
foods which can change over time
 A leaky gut is often an ongoing issue and frequently undiagnosed

24. DISRUPTED
METHYLATION/SULFATIO
N
GENETICS
ANTIBIOTICSVACCINATIONS
INFLAMMATION
GUT PERMEABILITY
GUT DYSBIOSIS
TOXICITY
Gluten/Casein
(opiates)
Food sensitivities
(endorphins)
Gut inflammation
Toxins
(bacterial/yeast)
Compromised
detoxification
Compromised
digestion
Dysregulated immune
function
Heavy metal toxicity Increased virus
exposure
DIET

25. There are at least three ways gut microbes are
communicating with the brain:
Directly through the vagal nerve, which
connects the network of nerves in the gut to the
brain
Through circulating immune cells that are
primed, or educated, in the gut and then travel to
the brain
Metabolites produced by microbes in the gut
that enter the blood and circulate to regions of
the brain where they affect behaviour
Petra AI, Panagiotidou S, Hatziagelaki E, Stewart JM, Conti P, Theoharides TC. Gut-Microbiota-Brain Axis and Its Effect on Neuropsychiatric
Disorders With Suspected Immune Dysregulation Clinical Therapeutics, Volume 37, Issue 5, 2015, 984–995

26. Pathway Effect
Afferent arm
Change of the gut microbiota due to usage of
antibiotics/infectious agents/probiotic bacteria
Alteration in the circulating levels of pro/anti-inflammatory
cytokines that affect brain function
Modulation of various host metabolic reactions Production of essential metabolites (e.g. bile acids, choline, short-
chain fatty acids)
Generation of neurotransmitters or neuromodulators in the
intestinal lumen
Induction of epithelial cell release of molecules that stimulate
afferent axons
Changes in tryptophan metabolism Effects on behaviour
Activation of sensory vagal fibres Conveyance of information about the state of the intestine to the
central nervous system
Efferent arm
Hypothalamic pituitary adrenal (HPA)-axis activation Regulation of immune cells locally in the gut and systematically
affecting gut permeability, motility, secretion, barrier function,
and gut microbiota composition
Anti-inflammatory cholinergic reflex and/or sympathetic
activation
Release of neurotransmitters that may affect gut microbiota
composition, intestinal permeability, and local immunity
Activation of central nervous system regulatory areas of satiety Impact on nutrient availability to intestinal microbiota and their
composition
Petra AI, Panagiotidou S, Hatziagelaki E, Stewart JM, Conti P, Theoharides TC. Gut-Microbiota-Brain Axis and Its Effect on Neuropsychiatric
Disorders With Suspected Immune Dysregulation Clinical Therapeutics, Volume 37, Issue 5, 2015, 984–995

27.  Children with ADHD may be influenced by the absorption of gut-derived bacterial
toxins
 Altered gut flora also leads to increased gut permeability and elevated levels of
inflammatory mediators
 Several studies have shown that the integrity of the intestinal lining is compromised in
both ADHD and ASD
 Increased gut permeability could lead to the absorption of microbial by-products as
well as partially digested food-derived compounds that may affect brain cell function
directly or lead to immune responses that could also affect brain cells
 Since probiotics can also improve the gut barrier, they may provide additional benefits
in ADHD and ASD through additional mechanisms
 With approx 80% of the immune system present within the gut, probiotics may also
favourably affect the immune system to reduce the gut inflammation often observed
in children with ADHD

28. Lactobacillus rhamnosus - helps repair leaky gut, reduces Candida cell numbers
Lactobacillus reuteri reduces Candida cell numbers
Lactobacillus plantarum reduces gut wall permeability. This bacterium adheres to
reinforce the barrier function of the intestinal mucosa, thus preventing the attachment
of the pathogenic bacteria to the intestinal wall
Lactobacillus fermentum - antimicrobials that inhibits the growth of some harmful
pathogens
Lactobacillus bulgaricus and lactobacillus breve ferment sugars into lactic acid, thereby
increases the acidity of the intestine, inhibiting the reproduction of harmful microbes
(e.g. Candida, that prefers an alkaline environment) and strains with known microbial
activity
http://www.probiotic.org

29. The importance of PUFA and neurological development
Third trimester Preterm

30. The developing brain
Long-chain fatty acid accumulates in the
normally growing foetal brain, which
accumulates around 67 mg/day in the last
trimester.
Total brain volume undergoes an initial rapid
spurt, reaching 80% of its maximum volume
by around 1.5 years.
Further growth spurts are believed to occur
between 2–4 years and between 6–8 years of
age.
Groeschel S, Vollmer B, King MD, Connelly A.
2010 Developmental changes in cerebral grey and white matter
volume from infancy to adulthood. Int J Dev Neurosci. 28:481-9.

31. PUFA deficiency using animal models
• The cerebral cortex regions, such as the frontal cortex where the omega-3 concentration is
very high, are particularly affected by omega–3 polyunsaturated fatty acid deficiency
• The frontal lobe contains most of the dopamine-sensitive neurons in the cerebral cortex
• PUFA deficiency in rodents results in behavioural changes (increased motor activity and
decreased learning abilities) and dysregulation of monoamine neurotransmission
• Symptoms can be reversed when polyunsaturated fatty acids are reintroduced into the diet
Carrié I et al. 2000 Specific phospholipid fatty acid composition of brain regions in mice. Effects of n-3 polyunsaturated fatty acid deficiency and phospholipid
supplementation. J Lipid Res. 41:465-72.
Transler C et al. 2011 Could Polyunsaturated Fatty Acids Deficiency Explain Some Dysfunctions Found in ADHD? Hypotheses From Animal Research. Atten Disord.
[Epub ahead of print]

33. Membrane alterations:
rafts; order; trafficking
Signal transduction pathways
leading to gene expression
Altered inflammatory cell
phenotype
Altered composition of inflammatory cell
phospholipids (more EPA & DHA; less AA)
Altered inflammatory response
EPA & DHA
Lipid mediators (e.g.
less PGE2 & LTB4)

34.  A deficiency of essential fatty acids (precursors for LC-PUFAs) as the cause of
ADHD was proposed 32 years ago
 Accumulating evidence has since supported that hypothesis, along with the
idea that omega-3 fatty acid deficiency may also play a major role in the
aetiology of ADHD and autism because there is a high male to female ratio
(between 3 and 5) for both disorders
 Females are born with more omega-3 EPA and DHA than males and are also
better able to convert ALA to EP and DHA (oestrogen enhances converting
enzymes whereas testosterone inhibits them)

35. Polyunsaturated fatty acids
 Deficiencies or imbalances in the long-chain highly unsaturated omega-3 fatty acids
have been implicated in the predisposition and development of neurodevelopmental
disorders (Richardson & Ross 2000; Richardson 2006)
 Lower RBC levels of EPA and DHA and a higher AA to EPA ratio in children with
ADHD than age-matched controls (Stevens et al., 1995; Burgess et al., 2000; Germano
et al., 2006; Antalis et al., 2006)
 This is thought to be due to:
Lack of dietary intake
Inefficient conversion from parent fatty acids
Enhanced metabolism
Biomarkers of fatty acid status:
Omega-3 index
AA to EPA ratio

36. Omega-3 intervention studies and ADHD
 Fish oil studies produce conflicting and often contradictory findings!
 Meta-analysis of 10 dietary omega-3 supplementation trials (699
children with ADHD) showed EPA-rich preparations were significantly
associated with clinical efficacy
Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention deficit/hyperactivity disorder symptomatology:
systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011 Oct;50(10):991-1000.

37. Omega-3 intervention studies and ADHD
Cochrane review shows a non-significant trend for improvement with the use of PUFA in
ADHD and significantly higher likelihood of improvement in the groups receiving omega-3 & -6
PUFA (GLA)
The majority of data showed no benefit of PUFA supplementation, although there were some
limited data that did show an improvement with combined omega-3 and omega-6
supplementation
It is important that future research addresses current weaknesses in this area, which include
small sample sizes, variability of selection criteria, variability of the type and dosage of
supplementation, short follow-up times and other methodological weaknesses
Gillies D, Sinn JKh, Lad SS, Leach MJ, Ross MJ. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in
children and adolescents. Cochrane Database Syst Rev. 2012 Jul 11;7:

38. Puri BK, Martins JG. Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid validate
meta-regression analysis of randomized controlled trials. Prostaglandins Leukot Essent Fatty Acids. 2014 May;90(5):179-89.

39. Issues with ‘fish oil’ studies
Heterogeneity of design and other factors may have
influenced responses and results:
 Duration of treatment
 Measurement of response
 Type and dose of fatty acid employed:
Omega-3 or omega -6
Long-chain vs short-chain
EPA vs DHA
EPA to DHA ratio
Inclusion of GLA

40.  EPA dose was
associated with
decreases in all
symptoms and DHA
dose an increase in
all symptoms
 2014 meta-analysis of ADHD rating scale outcomes of the 18 included
studies showed a small but significant decrease in all symptoms
(inattention + hyperactivity-impulsivity) with PUFA supplementation

42.  On multivariable meta-regression analysis, GLA and an interaction
between GLA and EPA were significantly associated with symptoms
 EPA and GLA within the treatment product and the length of
treatment regime are key influencers of outcomes (Puri & Martins 2014)
Results support those reported in the 2012 study by Perera and
colleagues, in which they use a pure EPA combined with evening
primrose oil as a source of GLA (Perera et al., 2012)
Puri BK, Martins JG. Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid
validated meta-regression analysis of randomized controlled trials. Prostaglandins Leukot Essent Fatty Acids. 2014 May;90(5):179-89.

43. Perera H, Jeewandara KC, Seneviratne S, Guruge BC. Effectiveness of combined omega-3 & omega-6 in children with attention deficit
hyperactivity disorder: a double-blind placebo-controlled trial. Sri Lankan College of Psychiatrists Annual Academic Meeting and conference.
February 2011
A double-blind, randomised, placebo-controlled trial shows that omega-3 EPA and
omega-6 GLA are an effective treatment combination for drug-resistant children with
ADHD
• 94 children diagnosed with ADHD
- aged 6-12 years
- 560mg ethyl-EPA and 18mg GLA daily, combined with methylphenidate
- placebo capsules, combined with methylphenidate
• Assessed at 3 and 6 months
• After 6 months, the treatment group showed significant improvements when compared to
the control group in the following areas:
– reduction in aggression
– improved educational functioning
– improved social relationships
– improved cooperation with parent and improved cooperation with teachers

44. Perera H, Jeewandara KC, Seneviratne S, Guruge BC. Effectiveness of combined omega-3 & omega-6 in children with attention deficit
hyperactivity disorder: a double-blind placebo-controlled trial. Sri Lankan College of Psychiatrists Annual Academic Meeting and conference.
February 2011

45. EPA and DHA utilisation differences
High DHA intake reduces delta-6-desaturase activity
Studies often report no increase in DHA levels with pure EPA
supplementation – DHA saturation?
In some cases [depression/neurodevelopmental disorders] high DHA
supplementation has been shown to worsen health outcomes
 12 week intervention with 1.8 g omega-3 (1.2g EPA + 0.6g
DHA) in young healthy males aged 18-25
 During the washout period, EPA and DHA levels decreased
back to baseline levels, with EPA levels rapidly returned to
baseline levels within 2 weeks of stopping fish oil
supplementation, while serum DHA returned to baseline
levels only by the end of the washout period
Suggests high EPA requirements
Roke K, Mutch DM: The role of FADS1/2 polymorphisms on cardiometabolic markers and fatty acid profiles in
young adults consuming fish oil supplements. Nutrients 2014, 6:2290-2304
Time (weeks)

46. • Increased HPA-axis activity
• Increased cortisol production
• Increased IDO/TMO/KMO activity
• The kynurenine (KYN)/tryptophan ratio
• Increased SERT activity/low serotonin
• Decreased neurotrophins
• Decreased neurogenesis
• Increased hippocampal atrophy
• Decreased delta-6 desaturase activity
• Increased COX-2, PLA2 & PGE2 activity
High AA to EPA ratio
Low omega-3 status
Cytokines
Cortisol
+ Symptoms

47. • Reduced HPA-axis activity
• Reduced cortisol production
• Reduced IDO/TMO/KMO activity
• Balanced kynurenine (KYN)/tryptophan ratio
• Balanced SERT activity/low serotonin
• Increased neurotrophins
• Increased neurogenesis
• Increased hippocampal atrophy
• Increased delta-6 desaturase activity
• Decreased COX-2, PLA2 & PGE2 activity
Lower AA to EPA ratio
High omega-3 status
Cytokines
Cortisol
- Symptoms

48. S.M. O’Mahony, G. Clarke, Y.E. Borre, T.G. Dinan, J.F. Cryan Serotonin, tryptophan metabolism and the brain-gut-microbiome axis Behavioural
Brain Research, Volume 277, 2015, 32–48
The kynurenine pathway of tryptophan metabolism

49. Interventions focus on:
Major food groups: reducing sugar, increasing quality protein
Eliminating/reducing dietary allergens
Restoring normal gut flora
Treating nutritional deficiencies: nutritional supplementation
• Children with ADHD are often associated with low plasma levels
of zinc, iron, vitamin B6 and magnesium
• Zinc, vitamin B6 and magnesium are essential cofactors in the
production of serotonin, dopamine and noradrenaline,
neurotransmitters critical in the aetiology of ADHD

50.  SAMe – metabolism of neurotransmitters
serotonin, melatonin and dopamine
 Cysteine and glutathione – vital for antioxidant
protection and detoxification processes
 DNA – cell cycle, genetic replication, growth
and development
 Carnitine, choline and CoQ10 – energy
metabolism and mitochondrial function
 Myelin proteins – nerve transmission and CNS
communication
A healthy methylation cycle – necessary for the production of:

52. Methionine
recycling
Methionine SAM: universal methyl donor
Methylates: neurotransmitters,
proteins, RNA, DHA,
catecholamines,
phosphatidylcholine,
melatonin, myelin, creatine
Precursor to carnitine
Inactivates histamine
Homocysteine
SAM
SAH
Methionine
synthase
5-methyl THF
THF
FOLIC ACID
CYCLE
Processes affected
Neurotransmitter function
Fatty acid metabolism
Allergic responses
Myelination
Cellular energy
Cell membrane and protein
structure and function
Cystathionine
Virus fighting
Inflammation regulation
Antioxidant production
Detoxification
Intestinal integrity
Cysteine
Glutathione
Metallathionines
Affects potent metal-
binding and redox
capabilities
Cysteinesulflinic acid
Phenol sulfur-
transferase
Phenol
processing
Digestion
Detoxification
Blood brain barrier
Gut barrier
Sulphate
Sulphite
Taurine
Production of
bile salts
Seizures
SULPHATION
TRANSSULFURATION
METHYLATION
S-adenosylmethionine (SAM), S-adenosylhomocysteine (SAH ); tetrahydrofolate (THF)

53. Methionine
recycling
Methionine SAM: universal methyl donor
Methylates: neurotransmitters,
proteins, RNA, DHA,
catecholamines,
phosphatidylcholine,
melatonin, myelin, creatine
Precursor to carnitine
Inactivates histamine
Homocysteine
SAM
SAH
Methionine
synthase
5-methyl THF
THF
FOLIC ACID
CYCLE
Processes affected
Neurotransmitter function
Fatty acid metabolism
Allergic responses
Myelination
Cellular energy
Cell membrane and protein
structure and function
Cystathionine
Virus fighting
Inflammation regulation
Antioxidant production
Detoxification
Intestinal integrity
Cysteine
Glutathione
Metallathionines
Affects potent metal-
binding and redox
capabilities
Cysteinesulflinic acid
Phenol sulfur-
transferase
Phenol
processing
Digestion
Detoxification
Blood brain barrier
Gut barrier
Sulphate
Sulphite
Taurine
Production of
bile salts
Seizures
SULPHATION
TRANSSULFURATION
METHYLATION
Magnesium
Magnesium, vitamin B6, zinc
Vitamin B6
S-adenosylmethionine (SAM), S-adenosylhomocysteine (SAH ); tetrahydrofolate (THF)

54. Methionine
recycling
Methionine
Homocysteine
SAM
SAH
Methionine
synthase
5-methyl THF
THF
FOLIC ACID
CYCLE
Disrupts gene expression
Decreased neurotransmitter function
Decreased myelination
Disrupted cellular energy transfer
Disrupted fatty acid metabolism
Increased allergic reactions
Cystathionine
Reduced
detoxification
of toxins and
heavy metals
Cysteine
Glutathione
Metallathionines
Affects potent metal-
binding and redox
capabilities
Cysteinesulflinic acid
Phenol sulfur-
transferase
Poor phenol
processing
Poor
digestion
Sulphate
Sulphite
Taurine
Production of
bile salts
Seizures
SULPHATION
TRANSSULFURATION
METHYLATION
Gut and blood brain
barrier integrity
compromised
Poor
detoxification
Inactivates
MAT and
decreases
SAM synthesis
Villi flatten
and lose
function
Reduced
antioxidant
function
Th1 decreases
Th2 increases
S-adenosylmethionine (SAM), S-adenosylhomocysteine (SAH); methionine adenosyltransferase (MAT; tetrahydrofolate (THF)

56. Fatty acid testing?
Benefits of the Opti-O-3
 Knowledge of baseline levels will guide the practitioner recommendations—
unsurprisingly, low baseline values may require a larger dose than a high
baseline value!
 The omega-3 index and AA to EPA ratio are invaluable for assessing both
baseline risk and the change in risk (as function of intake – retesting is
advisable ≥6 months )
 Dose response studies show us that high doses of omega-3 are generally
required to reduce the AA to EPA ratio and achieve omega-3 index ≥8%,
especially where the baseline levels are suboptimal ≤4%
 Intervention with EPA or include DHA?

57. Omega-3 index
an early cardiovascular risk indicator
Omega-6 to omega-3 ratio
an established marker of long-term health and chronic illness
AA to EPA ratio
a measure of ’silent’ or chronic inflammation
A personalised plan aims to achieve:
an omega-3 index of more than 8%
an omega-6 to omega-3 ratio of between 3 and 4
an AA to EPA ratio of between 1.5 and 3

58. • Igennus is the only independent manufacturer
of specialist Fatty Acid in the UK. Based in
Cambridge the medical innovation hub for the
UK:
- Seven Seas Merck Pharma Germany
- Minami Atrium Pharma Canada
- Biocare Elder Pharma India
- Eskimo 3 Bringwell Pharma Sweden
- Equizen Vifor Pharma Swiss
Vegepa | High strength EPA fish oil with GLA omega-3 & omega-6
Vegepa provides a combination of pure EPA omega-3 from 70% concentration
wild anchovy fish oil and omega-6 GLA from organic cold-pressed evening
primrose oil, with vitamin E for extra antioxidant protection of the oils. Vegepa
balances and maintains healthy omega-3 and omega-6 levels and is a highly
effective all-round supplement that offers medium intensity nutrition support,
ideal for general wellbeing maintenance.
HIGH STRENGTH 560 MG EPA DOSE from 70% concentration fish oil offers
medium intensity support for all-round health and wellbeing
ULTRA-PURE: wild anchovies are small and short-lived, so they are less prone
than larger species to pollutant build-up. Molecularly distilled to remove
dioxins, mercury & PCBs to virtually undetectable levels
ORGANIC EVENING PRIMROSE OIL: Premium organic cold-pressed virgin
evening primrose oil contains botanical triterpene antioxidants that protect
against free radicals
RESEARCHED FORMULA: used in double-blind placebo controlled trial in 96
children with ADHD and produced statistically significant improvements in 10
out of 11 measures
SMALL CAPSULES that are easy-to-swallow

59. • Igennus is the only independent manufacturer
of specialist Fatty Acid in the UK. Based in
Cambridge the medical innovation hub for the
UK:
- Seven Seas Merck Pharma Germany
- Minami Atrium Pharma Canada
- Biocare Elder Pharma India
- Eskimo 3 Bringwell Pharma Sweden
- Equizen Vifor Pharma Swiss
Pharmepa MAINTAIN | 1000 mg EPA & DHA wild omega-3 fish oil
(rTG omega-3) & vitamin D3
Containing pharmaceutical-grade 80% omega-3 concentrate, Pharmepa
MAINTAIN is more than 2.5x the strength of ordinary fish oil. Pharmepa
MAINTAIN contains an optimal ratio of 750 mg EPA, 250 mg DHA and 60
mg GLA for lifelong health, with additional support from vitamins D3
and E.
INTENSIVE 1000 MG OMEGA-3 DOSE supports brain development and
function, eye health, mood, inflammation regulation, pregnancy and
heart health
SUPERIOR OMEGA-3 FORM: rTG is body-ready, meaning that it is
digested and absorbed faster and increases levels of omega-3 in our
cells 5x more than krill oil and 3.5x more than standard fish oil
ULTRA-PURE: wild anchovies are small and short-lived, so they are less
prone than larger species to pollutant buildup. Molecularly distilled to
remove dioxins, mercury & PCBs to virtually undetectable levels
SUPER CONCENTRATED TO 80%: 2.5x the concentration of standard fish
oil, this supplements supports higher doses without exposure to heavy
metals, PCBs and dioxins
LEMON OIL PREVENTS FISH REFLUX

60. • Igennus is the only independent manufacturer
of specialist Fatty Acid in the UK. Based in
Cambridge the medical innovation hub for the
UK:
- Seven Seas Merck Pharma Germany
- Minami Atrium Pharma Canada
- Biocare Elder Pharma India
- Eskimo 3 Bringwell Pharma Sweden
- Equizen Vifor Pharma Swiss
NeurobalanceTM
NeurobalanceTM
is a blend of magnesium, zinc and vitamin B6,
formulated to aid in normal neurotransmitter production and
function. This scientifically formulated supplement offers synergistic
benefits to optimise the functioning of the nervous system. Utilising a
slow-release delivery system and the most bioavailable forms of each
ingredient, NeurobalanceTM
ensures optimal blood plasma nutrient
levels are maintained throughout the day.
 Highly bioavailable nutrients
 Synergistic relationship between Mg and B6
 Easy-to-swallow tablets
 Split-dosing for optimal bioavailability
 Sustained-release tablets for enhanced
absorption & optimal tissue distribution
 Offers benefits for brain function and mood
balance
 Supports neurotransmitter metabolism
 Supports neurological function
 Supports hormone balance
 Supports immune function
 Supports DNA and protein synthesis
 Aids in the production of sleep modulators
 Supports a healthy mood
 Anti-anxiety benefits

61. NeurobalanceTM
Zinc methionine offers superior bioavailability, antioxidant and immune-enhancing properties
compared to other forms of zinc.
Magnesium citrate is more soluble and bioavailable than magnesium oxide found in many cheaper
supplements.
Magnesium is required for the proper functioning of alkaline phosphatase, the enzyme that
facilitates the absorption of vitamin B6.
Pyridoxal-5-phosphate delivers the ‘body-ready’ form of vitamin B6.
Vitamin B6 is required for transport or accumulation of magnesium in cells and tissue.

62. NeurobalanceTM
Ingredients
Magnesium citrate; bulking agent: calcium carbonate; emulsifier: microcrystalline
cellulose; zinc methionine; vitamin B6 (pyridoxal-5-phosphate); thickener: hydroxypropyl
methylcellulose; anti-caking agents: stearic acid, silicon dioxide, magnesium stearate.
Nutritional information
Serving size: 2 tablets Amount per tablet % RDA
Zinc methionine 14 mg 140 %
Magnesium citrate
of which magnesium
367mg
60 mg 16 %
Vitamin B6 (pyridoxal-5-phosphate) 10 mg 714%

63. Dosing guide
Adults and children 12+ Dose
Vegepa 6-8 capsule daily
Neurobalance 2 x 3 tablets daily
Children aged 8-12
Vegepa 3-4 capsule daily
Neurobalance 2 x 2 tablets daily
Children aged 4-8
Vegepa 3-4 capsule daily
Neurobalance 1-2 x 2 tablets daily

64. Education Technical
Sophie Tully
Nutrition Education Manager
sophiet@igennus.com
Dr Nina Bailey
Head of Nutrition
ninab@igennus.com

66. ‘RESTORE’
pure EPA
‘MAINTAIN’
EPA, DHA and GLA
Minimum 3-6 months
 AA to EPA ratio
 Inflammatory regulation
 Symptoms of inflammatory illness
 Optimum brain, cell, heart, immune
and CNS function
 Optimum wellbeing
 Omega-3 index
 AA to EPA ratio
 Long-term general and cellular health
 Heart, brain and eye health
 Reduce risk of chronic illness and help
protect against inflammatory disease
Therapeutic role of Pharmepa®
RESTORE & MAINTAIN™