Pediatrics International (2017) 59, 408–415 doi: 10.1111/ped.

13196

Original Article

Nutritional status and feeding problems in pediatric attention deficit–

hyperactivity disorder

Norsuhaila Sha’ari,1 Zahara Abdul Manaf,2 Mahadir Ahmad3 and Fairuz Nazri Abd Rahman4
1
Department of Dietetics and Food Service, Kuala Lumpur Hospital, 2Dietetic Department and 3Health Psychology
Programme, Faculty of Health Sciences, and 4Psychiatry Department, Faculty of Medicine, National University of
Malaysia, Kuala Lumpur, Malaysia

Abstract Background: Children with attention deficit–hyperactivity disorder (ADHD) may be at risk of nutrient deficiency
due to the inability to sit through meals. This comparative cross-sectional study was therefore carried out to deter-
mine the nutritional status and feeding problems of ADHD children aged 4–12 years.
Methods: Sociodemographic data, anthropometric measurements and 3 day dietary intake record were collected
from 54 ADHD children and 54 typical development (TD) children. The Behavioral Pediatrics Feeding Assessment
Scale was used to assess feeding problems.
Results: Mean subject age was 8.6  2.1 years. On anthropometric assessment, 11.1% of the ADHD children had
wasting, while 1.9% had severe wasting. In contrast, none of the TD children had wasting. Approximately 5.6% of
the ADHD children had stunting, as compared with 3.7% of the TD children, while none of the TD children had
severe stunting compared with 3.7% of the ADHD children. More than half of the ADHD children had mid-upper
arm circumference (MUAC) below the 5th percentile, indicating undernutrition, compared with only 35.2% of TD
children. More than one-third of the ADHD children had feeding problems compared with 9.3% of TD children.
There was a significant negative relationship between the ADHD children’s feeding problems and bodyweight
(r = 0338, P = 0.012), body mass index (r = 0322, P = 0.017) and MUAC (r = 0384, P = 0.004).
Conclusion: Almost half of the ADHD children had suboptimal nutrition compared with 11.1% of the TD children.
It is imperative to screen ADHD children for nutritional status and feeding problems to prevent negative health
impacts later on.

Key words attention deficit–hyperactivity disorder, child, feeding problem, nutrition.

According to the Diagnostic and Statistical Manual of Mental
Disorders fifth edition (DSM-5), attention deficit–hyperactivity
disorder (ADHD) is characterized by a persistent pattern of
inattention, and/or hyperactivity–impulsivity that causes
impairment in at least two settings (e.g. school and home).1 It
is a neuropsychiatric disorder with early childhood onset
≤12 years of age and duration ≥6 months.
The prevalence of hyperactivity and inattention in a com-
munity survey of Malaysian children and adolescents aged 5–
15 years, was 3.9%.2 This is similar to US estimates of 3–5%
for ADHD in school-age children, based on DSM-4 diagnostic
criteria.3 The pooled prevalence of ADHD in children
<18 years old worldwide was 5.29% based on DSM-4 and
International Statistical Classification of Diseases and Related
Health Problems 10th edition diagnostic criteria.4
Correspondence: Fairuz Nazri Abd Rahman, MB ChB, MMedP-
sych, AdvMChAdoPsych, Psychiatry Department, Faculty of
Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000,
Malaysia. Email: fairuzn@ppukm.ukm.edu.my
Received 16 October 2015; revised 2 August 2016; accepted 30
September 2016.
Children with ADHD are at risk of nutritional and feeding
problems. The impulsivity and poor behavioral regulation
often found in children with ADHD may lead to the develop-
ment of eating patterns that put them at increased risk for obe-
sity.5 Stimulants such as methylphenidate, as well as non-
stimulants such as atomoxetine, have been widely used in the
treatment of school-aged children with ADHD.6,7 Weight loss
and decreased appetite are known adverse effects of the medi-
cations.8,9 In a cross-sectional study by Waring and Lapane,
children and adolescents with ADHD not currently on medica-
tions, aged 5–17 years in the USA, had 1.5-fold the odds of
being obese with no elevated risk of being overweight.10 In a
systematic review by Cortese et al.,11 many studies reported
increased body mass indices among children with ADHD.
Diet and supplements continue to be a popular explanation
of the etiology of ADHD,12–14 but there has been limited
research characterizing both dietary intake and eating patterns.
Children with ADHD may be at risk for a variety of nutrient
deficiencies due to the attention demands required to sit
through a meal to obtain an adequate level of nutrient intake,
as well as the appetite suppressant effects of medication.15
There are six studies on dietary intake in ADHD: one on

© 2016 Japan Pediatric Society


ADHD in preschoolers;16 three assessing dietary intake in
school-age children in Taiwan,17 Poland18 and Canada;15 one
study assessing dietary intake in the USA;19 and another study
in Iran.20 This comparative cross-sectional study was carried
out to determine the nutritional status and feeding problems in
Malaysian children with ADHD.
Methods
This comparative cross-sectional study compared 54 children
with ADHD who sought treatment at the Child and Adolescent
Psychiatric Clinic at Kuala Lumpur Hospital and National
University of Malaysia (Universiti Kebangsaan Malaysia;
UKM) Medical Centre with 54 typical development (TD) chil-
dren from various childcare centers and primary schools in
Kuala Lumpur and Selangor. The children with ADHD had
been diagnosed clinically by the child and adolescent psychia-
trists there according to DSM-5. The ADHD and intellectual
levels of all of the children were only clinically assessed and
not assessed formally with scales. Any clinically identified
comorbidities such as autism spectrum disorder (ASD) and
any other neurodevelopmental disorders were noted, and those
children included in the study. In addition, the medication sta-
tus of the children with ADHD was also elicited. The TD
group was selected on the basis that they were attending main-
stream education according to their age and not attending any
doctors for any developmental problems. Subjects were
recruited by convenient sampling. Random sampling could not
be carried out because there are no specific records of popula-
tions of children with special needs in Malaysia.21 The two
groups were similar for age, gender, race and socioeconomic
status. Approval for the study was obtained from the UKM
Research and Ethics Committee, the Ministry of Health and
the Ministry of Education. Prior written consent was obtained
from parents before their child was accepted as a subject.
Non-Malaysian children and children taking nutritional supple-
ments either via tube or orally were excluded.
Data collection
Anthropometry
Weight, height and mid-upper arm circumference (MUAC)
were measured. Weight (to the nearest 0.1 kg) was measured
using Tanita digital scales (model 318; Itabashi-Ku, Tokyo,
Japan) while height (to the nearest 0.1 cm) was measured using
a Seca stadiometer (model 206; Hamburg, Germany). Body
mass index (BMI) for age, height for age and weight for age
were used to determine growth status, according to the World
Health Organization (WHO) Growth Standards up to 5 years
old,22 and WHO Growth Reference for those aged >5 years.23
BMI-for-age z-score (BAZ) and height-for-age z-score (HAZ)
were computed to adjust for age and sex differences. The
MUAC measurements were compared with MUAC percentile-
for-age based on Frisancho.24 All of the anthropometric mea-
surements were done twice and the mean calculated.
Nutrition and feeding in ADHD 409
Dietary intake
Three day dietary intake record, consisting of two weekdays and
one weekend day, was obtained from a food diary kept by the
parents. Mean intake of energy, carbohydrates, protein, fat and
selected micronutrients – zinc, iron, thiamine, vitamin A, vita-
min C and copper, was calculated. Dietary data were analyzed
using Nutritionist Pro (Axxya Systems, Redmond, WA, USA).
Underreporting of energy is one of the common problems in
dietary assessment. In this study, underreporting of energy
intake was adjusted for based on the estimated ratio between
energy intake and basal metabolic rate by Torun et al.25
Questionnaire on feeding problems during mealtimes
Information on mealtime behaviors was gathered using the
Bahasa Malaysia translation of the Behavioral Paediatrics
Feeding Assessment Scale (BPFAS),26 a parent-report measure
that screens for feeding problems during mealtimes. Hashim
noted a Cronbach alpha of 0.73.27 This scale consists of 35
items. The first 25 items refer to the child’s behavior, while
the next 10 items refer to the parent’s feelings and strategies
for dealing with the feeding problems. Each item consists of a
descriptive phrase, for which the parent is requested to rate
how often the behavior occurs on a 5-point Likert scale from
never to always (1–5). The items are summed to produce fre-
quency scores and problem scores. A total frequency score
>84 indicates feeding problems during mealtimes. The higher
the score, the more feeding problems during mealtimes. The
parent was also asked whether or not the mealtime behavior
was a problem for them by circling “yes” or “no” alternatives.
Total problem score >9 signified that the children’s behavior
during mealtime troubled the family, especially the parents.
Statistical analysis
Data were analyzed using SPSS for Windows version 19.0
(IBM, Armonk, NY, USA). Data normality was checked using
Shapiro–Wilk test. Group comparisons with respect to quantita-
tive variables were carried out using independent t-test. Mann–
Whitney test was used for data not normally distributed. Group
comparisons of categorical data were done using chi-squared
test. Fisher’s exact test was used to determine the relationship if
the expected value (expected outcome) was <5 in a 2 9 2 table.
Spearman’s correlation test was used to analyze the relationship
between the anthropometric measurements and feeding prob-
lems. The significance level was set at P < 0.05.
Results
Sociodemographic and clinical background
A total of 54 ADHD subjects and 54 TD subjects were
recruited. The age of these children ranged from 4 to 12 years
old. Mean age was 8.6  2.1 years (Table 1). The two groups
were matched by age, gender, race and socioeconomic status.
© 2016 Japan Pediatric Society
410 N Sha’ari et al.

Each group consisted of 44 boys (81.5%) and 10 girls
(18.5%), at a ratio of 4:1. Two-thirds of the ADHD children
had medical and neurodevelopmental comorbidities. Seventy
percent of the ADHD children were on medication for ADHD.
The children were pooled into three groups: ages 4–6 years
(n = 10), 7–9 years (n = 22) and 10–12 years (n = 22). A
100% compliance rate was sought for both the questionnaire
and anthropometric measurements for both ADHD subjects
and TD subjects. All parents of TD subjects completed the
3 day food diary, while 98.1% of the parents of ADHD sub-
jects did so. More than half of the subjects’ families had a
household income in the range of RM1500–3500, and 27.8%
earned >RM5000 per month.
Furthermore, five ADHD subjects were obese compared with
nine TD subjects. In terms of height for age, 5.6% of the
ADHD subjects had stunting compared with 3.7% of TD sub-
jects. No TD subjects had severe stunting, compared with
3.7% of the ADHD subjects. A total of 55.6% of ADHD sub-
jects and 35.2% of TD subjects had MUAC for age <5th per-
centile, indicating undernutrition. Anthropometry by age group
was not statistically significantly different (P > 0.05), except
for weight in the 10–12 years age group (Table 2). On further
analysis, ADHD children who were on medication for ADHD
were not significantly different from ADHD children who
were not on medication in terms of weight (P = 0.704), height
(P = 0.557), MUAC (P = 0.579) and BMI (P = 0.626).

Anthropometry Dietary intake

According to BMI for age, 11.1% of the ADHD children had The dietary intake of 20.9% of the ADHD subjects was under-
wasting and 1.9% had severe wasting. None of the TD chil- reported compared with 18.1% of TD subjects, but they were
dren had wasting. Approximately 11.1% of ADHD subjects
were overweight compared with 5.6% of TD subjects. Table 2 Anthropometric data vs age

Weight (kg) ADHD (n = 54) TD (n = 54) P-value†

Table 1 Sociodemographic and clinical subject characteristics
n Mean  SD n Mean  SD
Characteristics ADHD (n = 54) TD (n = 54) Male 44 29.3  11.4 44 31.5  12.7 0.411
n (%) or n (%) or 4–6 years 8 19.4  3.4 8 19.8  3.6 0.598
mean  SD mean  SD 7–9 years 18 27.7  9.3 18 26.9  9.2 0.962
Gender 10–12 years 18 35.2  8.3 18 41.3  9.5 0.043*
Male 44 (81.5) 44 (81.5) Female 10 28.3  11.2 10 33.0  17.0 0.520
Female 10 (18.5) 10 (18.5) 4–6 years 2 18.5  1.5 2 17.1  1.3 0.439
Age (years) 8.6  2.1 8.6  2.1 7–9 years 4 23.5  4.4 4 27.8  6.6 0.191
Race 10–12 years 4 38.1  9.8 4 46.1  10.7 0.510
Malay 40 (74.1) 40 (74.1) Height (cm)
Chinese 13 (24.1) 13 (24.1) Male 44 130.3  13.1 44 131.3  13.2 0.614
Indian 1 (1.9) 1 (1.9) 4–6 years 8 109.5  7.2 8 114.5  7.9 0.875
Household income (RM per month) 7–9 years 18 111.8  9.2 18 126.6  8.4 0.776
≤1500 5 (9.3) 5 (9.3) 10–12 years 18 124.0  10.8 18 143.8  5.8 0.289
1500–3500 30 (55.6) 30 (55.6) Female 10 126.9  11.5 10 131.6  15.2 0.762
3501–5000 4 (7.4) 4 (7.4) 4–6 years 2 110.0  5.6 2 110.2  3.2 0.439
≥5000 15 (27.8) 15 (27.8) 7–9 years 4 113.0  7.4 4 130.2  5.0 0.149
Comorbidities 10–12 years 4 135.0  4.4 4 143.8  9.7 0.434
Yes 36 (66.7) BMI (kg/m2)
No 18 (33.3) Male 44 16.7  3.8 44 17.6  4.0 0.194
Type 4–6 years 8 12.3  0.9 8 15.0  1.5 0.290
Dyslexia 23 (32.9) 7–9 years 18 11.8  4.1 18 16.4  3.5 0.924
Speech impairment 13 (18.6) 10–12 years 18 12.7  3.8 18 19.8  4.3 0.071
Autism 11 (15.7) Female 10 17.0  3.9 10 17.9  5.0 0.970
Intellectual deficit 7 (10.0) 4–6 years 2 14.1  0.07 2 14.0  0.2 0.683
Developmental delay 4 (7.1) 7–9 years 4 13.9  2.6 4 16.3  3.4 0.885
Asthma 4 (5.7) 10–12 years 4 16.1  4.6 4 21.5  5.7 0.772
Others 7 (10.0) MUAC (cm)
Medication for ADHD Male 44 19.8  3.7 44 20.0  4.5 0.957
Yes 38 (70.4) 4–6 years 8 16.7  1.1 8 17.1  2.9 0.875
No 16 (29.6) 7–9 years 18 19.8  4.1 18 18.4  3.6 0.776
Stimulants 10–12 years 18 21.1  3.3 18 23.2  4.1 0.289
Methylphenidate 35 (92.1) Female 10 19.3  2.7 10 20.2  5.0 0.821
(Ritalin IR) 4–6 years 2 17.5  1.4 2 14.7  0.2 0.439
Concerta 1 (2.6) 7–9 years 4 18.2  2.5 4 19.2  3.8 0.149
Non-stimulants 10–12 years 4 21.4  2.4 4 24.1  4.3 0.912
Atomoxetine HCL 2 (5.3)
*P < 0.05. †Independent t-test. ADHD, attention deficit–hyper-
ADHD, attention deficit–hyperactivity disorder; TD, typical activity disorder; BMI, body mass index; MUAC, mid-upper arm
development. circumference; TD, typical development.

© 2016 Japan Pediatric Society

 Nutrition and feeding in ADHD 411

not excluded from the study because the aim was to describe
the overall energy and nutrient intakes of all samples obtained.
Table 3 lists the mean intake of energy and nutrients. There
were significant differences in energy and carbohydrate intake
between ADHD subjects and TD subjects. The ADHD sub-
jects consumed more energy and carbohydrate than TD sub-
jects. A total of 59.2% (n = 32) of ADHD subjects and 53.6%
(n = 29) of TD subjects achieved ≥100% reference nutrient
intake (RNI) for energy intake. All subjects achieved ≥100%
RNI for protein intake. There was no significant difference in
micronutrient intake between ADHD subjects and TD subjects
(Table 3).
Feeding behavior problems during mealtimes
Mean feeding behavior score in ADHD subjects was
77.4  12.3 compared with 57.7  13.9 for TD subjects.
There were significant differences (P < 0.001) in feeding
behavior scores between these two groups. Feeding problems
(total score >84) were significantly different between ADHD
subjects and TD subjects (P < 0.05): one-third (n = 16) of
ADHD subjects had feeding behavioral problems compared
with 9.3% (n = 5) of TD subjects. The feeding behavioral
problems were not significantly different according to age
group either in children with ADHD or TD children. Feeding
behavioral problems most often displayed by ADHD subjects
were: “tries to negotiate what she/he will eat and what she/he
will not eat” (90.7%), “gets up from the table during meals”
(88.9%), “takes >20 min to finish a meal” (83.3%), “reluctant
to try new foods” (81.5%), “delays eating by talking” (72.2%)
and “tantrums at mealtimes” (70.4%; Table 4). Around 90.7%
of ADHD subjects and 85.2% of TD subjects “tried to negoti-
ate what she/he will eat and what she/he will not eat”,
although there was no significant difference between these two
groups. In terms of “getting up from the table during meals”,
88.9% (n = 48) of ADHD subjects had this behavior com-
pared with 61.1% (n = 33) of TD subjects (P < 0.001). Feed-
ing behaviors that were more dominant in ADHD subjects
such as “taking >20 min to finish a meal”, “reluctant to try
new foods” and “tantrums during mealtimes” were signifi-
cantly different between ADHD subjects and TD subjects
(P < 0.05).
Mean feeding behavior score during mealtime was
8.1  4.6 for ADHD subjects and 2.2  1.5 for TD subjects
(P < 0.001; Table 5). There were significant differences
(P < 0.001) in feeding behavior that caused problems for par-
ents of ADHD subjects and TD subjects. Approximately
27.8% of ADHD subjects had feeding behaviors that caused
problems to parents, compared with only 3.7% of TD children.
“Gets up from table during mealtimes” was the most dominant
behavior that was considered the most problematic by 70.4%
of parents of ADHD subjects, compared with 5.6% of TD sub-
jects (P < 0.001). Other feeding behaviors that were signifi-
cantly different between ADHD subjects and TD subjects
were “tantrum during mealtimes” (P < 0.001), “delays eating
by talking” (P < 0.001) and “reluctant to try new foods”
(P < 0.001; Table 5). There was no significant difference in
refusal to eat vegetables between ADHD subjects and TD sub-
jects (P > 0.05).
Finally, there was a significant and negative relationship
between the ADHD subjects’ feeding problems and body-
weight (r = 0338, P = 0012), BMI (r = 0322, P = 0.017)
and MUAC (r = 0384, P = 0.004; Table 6).
Discussion
Clinical Practice Guidelines of ADHD stipulate that ADHD is
threefold more likely to occur in boys.3 Faraone et al. and

Table 3 Energy and nutrient intake

Energy/nutrients ADHD (n = 53) TD (n = 54) P-value

Mean  SD Range Mean  SD Range
Energy (kcal) 1679  333 1110–2775 1515  333 1045–2531 0.013*†
Protein (g) 58  13 37–91 57  14 37–103 0.772†
% protein 14  0.5 13–15 15  0.4 14–16
Carbohydrate (g) 235  53 150–415 199  45 127–341 <0.001*†
% carbohydrate 56  2 54–60 53  1.5 48–58
Fat (g) 57  13 35–87 54  16 33–95 0.132†
% fat 30  0.8 28–32 32  1.0 28–36
Calcium (mg) 439  210 49–986 420  209 107–1363 0.067‡
Iron (mg) 13  4.9 2.4–29 14  7.3 4.7–37 0.911‡
Zinc (mg) 3.5  1.9 0.9–10 3.6  1.5 0.8–8.6 0.647‡
Thiamin (mg) 0.7  0.2 0.2–1.5 0.6  0.2 0.3–1.3 0.414†
Riboflavin (mg) 1.0  0.4 0.3–2.6 0.9  0.4 0.3–1.3 0.402‡
Niacin (mg NE) 10  4.1 1.4–22 11  5.4 2.3–27 0.990‡
Vitamin C (mg) 29  26 1.2–98 24  20 0.6–87 0.432‡
Vitamin A (lg) 642  267 252–1218 761  342 201–1963 0.067‡
Vitamin E (mg) 3.2  1.8 0.2–8.4 3.7  1.9 1.1–9.6 0.131‡
Crude fiber(g) 3.3  1.7 0.5–7.0 3.2  2.0 0.4–8.6 0.442‡
*P < 0.05. †Independent t-test; ‡Mann–Whitney test. ADHD, attention deficit–hyperactivity disorder; NE, niacin equivalent; TD,
typical development.

© 2016 Japan Pediatric Society

412 N Sha’ari et al.

Table 4 Parents’ perception of feeding behavior during meal- Table 5 Feeding behaviors during mealtimes that caused prob-
times lems for parents

ADHD (n = 54) TD (n = 54) P-value ADHD TD P-value

n (%) or n (%) or (n = 54) (n = 54)
mean  SD mean  SD n (%) or n (%) or
Total frequency 77.4  12.3 57.7  13.9 <0.001†* mean  SD mean  SD
score of feeding Total frequency score of 8.1  4.6 2.2  3.5 <0.001*†
behavior during feeding behaviors that
mealtimes caused
Feeding problems during mealtimes (overall) problems for parents
Yes§ 16 (29.6) 5 (9.3) 0.007‡* Feeding behaviors that caused problems for parents
No¶ 38 (70.4) 49 (90.7) Yes 15 (27.8) 2 (3.7) 0.001*‡
Feeding problems Yes No Yes No No 39 (72.2) 52 (96.3)
by age group Feeding behavioral problems that often caused problems for
4–6 years 5 7 2 8 <0.001 parents
7–9 years 5 17 2 20 <0.001 Gets up from table 38 (70.4) 3 (5.6) <0.001*‡
10–12 years 8 14 1 21 <0.001 during meal
P = 0.937 P = 0.531 Tantrums at mealtimes 27 (50.0) 2 (3.7) <0.001*‡
(between (between Delays eating 26 (48.1) 2 (3.7) <0.001*‡
age groups) age groups) by talking
Feeding behaviors during mealtimes often displayed by subjects Dislikes vegetables 21 (38.9) 18 (33.3) 0.548‡
Tries to negotiate what s/he will eat and what s/he will not eat Will not try new foods 20 (37.0) 4 (7.4) <0.001*‡
Yes§ 49 (90.7) 46 (85.2) 0.375‡
No ¶
5 (29.3) 8 (17.8) *P < 0.05. †Independent t-test; ‡chi-squared test. ADHD,
Gets up from table during meal attention deficit–hyperactivity disorder; TD, typical development.
Yes§ 48 (88.9) 33 (61.1) 0.001*‡
No¶ 6 (11.1) 21 (38.9)
Takes >20 min to finish a meal Table 6 Nutritional status parameters vs feeding problems in
Yes§ 45 (83.3) 34 (63.0) 0.017*‡ ADHD subjects
¶
No 9 (16.7) 20 (37.0)
Will not try new foods Nutritional status parameter Feeding problems
Yes§ 44 (81.5) 32 (59.3) 0.014*‡ r P-value
No¶ 10 (18.5) 22 (40.7)
Delays eating by talking Bodyweight (kg) 0.338 0.012*
Yes§ 39 (72.2) 34 (63.0) 0.304‡ Height (cm) 0.260 0.058
No ¶
15 (27.8) 20 (37.0) BMI (kg/m2) 0.322 0.017*
Tantrums at mealtimes MUAC (cm) 0384 0.004*
Yes§ 38 (70.4) 20 (37.0) 0.010*‡ Energy intake (kcal) 0.160 0.247
No¶ 16 (29.6) 34 (63.0)
*P < 0.05. ADHD, attention deficit–hyperactivity disorder;
*P < 0.05. †Independent t-test; ‡chi-squared test. §Always and BMI, body mass index; MUAC, mid-upper arm circumference.
sometimes displayed; ¶never displayed. ADHD, attention deficit–
hyperactivity disorder; TD, typical development.
who suggested that catch-up growth occurred during puberty
in children with ADHD.12
Thapar and Munoz-Solomando indicated that boys were esti- In this study there was no significant difference in weight
mated to have a 2–9-fold risk of ADHD compared with in the 10–12-year-old ADHD subjects and TD subjects.
girls.28,29 The ratio of boys to girls in ADHD children was 4:1 ADHD subjects were lighter, with a mean bodyweight of
in this study, similar to the Bhatia et al. and Cantwell stud- 29.1  11.2 kg, compared with 31.8  13.4 kg in the TD
ies.30,31 The mean age of the ADHD subjects was group. A similar result was obtained for boys in the same age
8.6  2.1 years, with 18.5% aged >10 years old. A systematic group. This was similar to the Waring and Lapane study, in
review by Barkley et al.8 found that most patients were which no excess risk was detected in bodyweight in ADHD
referred to psychiatrists between 6 and 9 years of age, and children on stimulant medications or not.10 This is contrary to
diagnosed at around 8 years of age. the Cortese et al., Holtkamp et al. and Hubel et al. studies, in
The ADHD children are considered to need special care which there was an increasing prevalence of overweight in the
and attention. In this study, approximately 11.1% of ADHD ADHD group compared with healthy children.11,32,33 In the
subjects were overweight compared with 5.6% of TD subjects. previous studies, the prevalence of overweight in the ADHD
Five ADHD subjects, however, were obese, compared with children ranged from 19.6% to 29.0%, and obesity ranged
nine TD subjects. The prevalence of underweight was the from 7.2% to 17.3%. According to Hubel et al.,33 the
same between the ADHD and TD subjects, at 4%. Faraone impulsivity and hyperactivity seen in ADHD children might
et al.28 postulated that the effect of stimulant medication increase their food intake, subsequently leading to overweight.
decreased as the child grew older. This is supported by Sinn, Waring and Lapane, in their study of ADHD children aged

© 2016 Japan Pediatric Society


5–17 years in the USA, found that children with ADHD who
did not take any stimulant medication had 1.5-fold the risk of
being obese than children not diagnosed with ADHD.10 The
limitation of their study was that they examined only the
impact of growth in overweight children with ADHD who did
not take stimulants.
In the present study there were no significant differences in
height and BMI between ADHD children and TD subjects.
This is in line with Faraone et al.,28 and also the Kiddie et al.,
and Chen et al., and Biederman et al. studies, in which stimu-
lants did not have any adverse effects on weight or height sta-
tus,15,17,34 although it is often associated with stunting of
growth.12,35 According to Faraone et al.,28 this condition
decreased when the child grew older and reached puberty or
when they stopped taking stimulant medications.
There was also no significant difference in MUAC in the pre-
sent study. MUAC is the best anthropometric indicator of acute
malnutrition compared with weight for height. A total of 55.6%
of the present ADHD subjects had MUAC for age below the 5th
percentile, indicating undernutrition or lack of energy–protein
storage compared with 35.2% of TD children. Lack of energy–
protein storage during the early stages of childhood develop-
ment might have a long-term impact on the central nervous sys-
tem and thus interfere with neuropsychological function.
Energy and carbohydrate intake were significantly different
between the present ADHD subjects and TD subjects. Overall,
energy and carbohydrate intake was higher in ADHD subjects
than in TD subjects. Kiddie et al.15 also found that carbohy-
drate intake was higher in ADHD subjects than TD subjects,
but they had a lower energy intake. Both the Kiddie et al. and
Chen et al., studies, however, noted no significant differences
between energy and carbohydrate intake between children with
ADHD and healthy children.15,17 This is because dietary pat-
terns are endemic and are influenced by the local culture.
Therefore, studies carried out in other countries may not
reflect the food intake of Malaysian children.
In addition, micronutrient intake was not significantly dif-
ferent between the present ADHD and TD subjects. This is in
contrast to the Kiddie et al.15 study, in which significant dif-
ferences were noted for intake of vitamin B6, zinc and copper
between 36 ADHD children aged 6–12 years compared with
1581 TD children in Canada. Chen et al.17 noted significant
differences between children with ADHD and TD children in
Taiwan, in that the intake of iron and vitamin C was higher in
ADHD children. There is evidence to suggest that ADHD is
associated with a deficiency of zinc and iron.19 This is inter-
esting, given that zinc, iron and copper are required for the
production of the neurotransmitters dopamine and nore-
pinephrine, which play an important role in the etiology of
ADHD. ADHD children have been noted to have low dopa-
mine in the brain,36 which can subsequently be caused by low
serum zinc, iron and copper. Intervention studies or random-
ized clinical trials are needed to prove this relationship before
any conclusion can be made.
All of the present ADHD subjects and TD subjects
achieved ≥100% RNI for protein intake, but none of the
Nutrition and feeding in ADHD 413
subjects achieved ≥100% RNI for crude fiber intake. This may
be because of lack of interest, refusal to eat and not trained by
their parents to eat vegetables and fruits during childhood.
Narrow food choices and acceptance only of certain texture
and taste, require creativity by parents to encourage food
diversification in picky eaters.
One-third of ADHD subjects had behavioral feeding prob-
lems compared with 9.3% of TD subjects. This is in line with
Esparo et al.,37 who noted that 24.4% of children with ADHD
had feeding problems. This supports the March et al.38 study,
in which hyperactive children and children with psychiatric
problems were found to be susceptible to feeding problems.
Feeding problems often occur in children due to disruptive
behavior and altered appetite, which can lead to food rejection
and refusal to try new foods, which in turn affect growth and
weight status, subsequently leading to malnutrition.37 The
feeding problems most often displayed by the present ADHD
children, and which were significantly different to those of the
TD subjects, were: “gets up from the table (does not sit down)
during meals”, “takes >20 min to finish a meal”, “reluctant to
try new foods” and “tantrums at mealtimes”. A total of 83.3%
of ADHD subjects took >20 min to finish a meal compared
with 63.0% of TD subjects. This may be due to attention
problems. Around 48% of the ADHD subjects often got up
from the table during meals, and 38% had tantrums during
mealtimes, which are in line with the characteristics of
ADHD.
In addition, the present ADHD subjects had a 7.5-fold
prevalence of feeding problems compared with TD subjects.
ADHD children might be vulnerable to this due to their
hyperactive behavior and mental constraints that can lead to
rejection of food. This is supported by Crist and Napier-Phil-
lips, who noted that feeding behaviors during mealtime such
as delaying eating by talking and getting up from the table
during meals, are characteristic of food refusal in children.39
They found that the majority of food and energy intake in
these children were derived from unhealthy snacks between
meals.
The present study also found that 27.8% of ADHD subjects
had feeding behaviors that were considered problematic by
their parents compared with 3.7% of TD subjects. Feeding
behaviors that were considered problematic by parents, and
which were significantly different between ADHD subjects
and TD subjects, were: “got up from the table during meals”,
“reluctant to try new foods”, “tantrums at mealtimes”, and
“delays eating by talking”. “Taking >20 min to finish a meal”,
however, which was often displayed by ADHD subjects, was
not considered problematic by their parents. A total of 94.4%
of both parents of ADHD subjects and TD subjects felt confi-
dent in their ability to manage the behavior of their children
during mealtimes.
There was also a negative and significant correlation
between the parameters of nutritional status such as body-
weight, BMI and MUAC, with feeding problems in ADHD
subjects. The lower the bodyweight, BMI and MUAC in
ADHD subjects, the more feeding problems they encountered.
© 2016 Japan Pediatric Society
414 N Sha’ari et al.
This was similar to a study by Stein et al.,40 who found that
the lighter the child, the more conflicts they had with regard
to dietary issues. This supports the Crist et al.26 study, in
which behavioral problems reduced dietary consumption, thus
affecting energy and nutrient intake in children. In the present
study, however, there was no association between energy
intake and feeding problems in ADHD subjects.
Newmark, Pelsser et al., Schnoll et al. and Steer strongly
recommended that dietary intervention be carried out for all
children with ADHD as part of the ADHD treatment proto-
col.36,41–43 Therefore, children with ADHD should be screened
for problems with food intake as early as possible so that
appropriate nutritional intervention can be delivered.44 BPFAS
can be used for this.
A limitation of this study was that the ADHD and intellec-
tual levels of all of the children were only clinically assessed
and not assessed formally with scales. In addition, the sample
included ASD and other neurodevelopmental disorders, which
may have confounded the results. Children with ASD may
have feeding problems such as selective or restrictive food
intake. Also, feeding disorders such as selective or restrictive
food intake was not elicited. Therefore, this study had many
factors that may confound the results.
In conclusion, children with ADHD may be at risk for a
variety of nutrient deficiencies due to the inability to sit
through a meal to obtain adequate nutrient intake. In this
study, almost half of the ADHD children were indicated for
nutrition intervention compared with 11.1% of TD children. It
is imperative to screen ADHD children for nutritional status
and feeding problems in order to prevent negative health
impacts later in life.
Disclosure
The authors declare no conflict of interest.
Author contributions
N.S., Z.A.M., M.A. and F.N.A.R. contributed to the concep-
tion and design of this study; N.S. collected data, performed
the statistical analysis and drafted the manuscript; Z.A.M. crit-
ically reviewed the manuscript and supervised the whole study
process. M.A. gave technical support and conceptual advice.
F.N.A.R. edited the final manuscript. All authors read and
approved the final manuscript.
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© 2016 Japan Pediatric Society