Broad Spectrum Micronutrient Supplements in Child Mental Health

0:07 and so our beloved dr. Bo Gomez has kindly agreed to share some of her knowledge with us particularly on the use of broad-spectrum micronutrients so I will give this over to her I enjoy speaking about broad-spectrum micronutrients because I think that the evidence base is so strong and I find it one of the most powerful interventions for child mental health quite I would say easy but easier to learn and I talked to many pediatricians regularly with my with who I'm sharing a patient with and can easily inform them why I've chosen the modality that I did so just

0:53 briefly regarding nutrition I think we all know that we're not eating and especially teens and children are not eating the foods that they need and there's several studies this is just one of them showing that there's a direct correlation between not eating well and feeling poorly many people say well if you're not feeling well then you're gonna eat poorly and this specific study really highlights the fact that that that relationship is bi-directional if you're not eating well then you're also not gonna feel well even if your baseline doing okay so I know for myself I've been making a bowl of nine fruits and vegetables in the morning and then just snacking on them the entire day to help my immune system but I think that that's something again so many different studies show this and this talks this

1:39 this one highlights that the reverse causality meaning that if you're not feeling well you're eating poorly it does not explain the full effect of the influence of nutrition on mental health the other thing that I think is important to mention is that when as a child psychiatrist I talked to kids a lot about eating well and I say I want you to eat well 80% of the time and then 20% of the time you know eat your favorite foods because I do think that there can be a risk of just focusing on healthy foods as I do see kids develop eating disorders as well as worth orthorexia when we just focus on just healthy foods and interestingly a study done in 2012 shows that the the quartile that did they divided up the participants and how well they were

2:24 eating in three different quartiles and the one with the best eating and the one with the second-best seating were equivalent but they did a lot better than the ones who were eating the worst the lots of junk food so I took the takeaway message I get from that is you don't have to have a perfect diet as far with kids and with adolescents you just want to have like a pretty good diet so I talked to kids you know 80% of the time eat well but unfortunately I think it's the reverse that we're actually seeing most of the time because kids are eating you know this is no news for us we have the standard American diet I do think that there's an issue with and the data supports this that we're not getting enough of the calcium magnesium zinc that we need and even if for a variety of reasons including food deserts and you know school lunches and

3:11 lots of different factors involved and also that this is something I tell all the parents when I'm prescribing micronutrients is that the fruits and vegetables that were eating today don't have the same amount of mineral and vitamins that they did 50 years ago because of eating out of season because of the agricultural changes and to me this is a big big piece of why micronutrients help so many kids even the ones that might be having an okay diet this is a fantastic review article and basically the take-home message to this is that we spend a lot of time in academia researching one mic a single micronutrient let's look at folate let's look at chromium let's look at magnesium and all the studies when you look at

3:57 just one micronutrient has usually a small effect size but when you look at the studies using broad-spectrum micronutrients the effect size is usually a more of a moderate effect size because you're giving the body a variety of minerals and vitamins and minerals and allowing it to use what it needs so these are the two study there have been where I use micronutrients the most are in kids with mood dysregulation and we see that a lot with kids with ADHD I'd say one of the primary things that I see in my practice are kids with ADHD who had start been started on a stimulant they're doing you know better with focus and attention but they still have severe mood dysregulation and I and I also see a lot of kids who

4:43 can't tolerate stimulants and they get worse and pretty much ate I'd say about 80% of the time they might clinical experience and the data shows this a little bit lower in research studies about sixty to eighty percent of the time do you see significant improvement in mood dysregulation attention focus hyperactivity so these are two of the sets so there were there was first in Oakland label studies showing improvement with micronutrients and that was followed by a double-blind placebo-controlled trial and children using micronutrients with improvements and this over here improvement of CGI scores and again the main thing I see improvement with is emotional dysregulation and aggression as well all

5:29 those many improve in inattention and hyperactivity there is currently a second which is very exciting when you have to - this is the second study done in children a double-blind placebo-controlled trial showing preliminary results of also the same improvement in mood dysregulation in children and also there is a study in adults with ADHD also a double-blind placebo-controlled trial showing improvement in ADHD symptoms so there are these different studies here interestingly they looked at in this study the children who were given the broad spectrum micronutrients in the ADHD study showed it increased in the diversity

6:19 an increase in the diversity of the bacteria in the gut over the 10 weeks which researchers did not see in the group exposed to placebo so there are many studies coming out looking at probiotics and I think right now the conclusion is we don't know exactly there's not a consensus of what probiotic we should be recommending to patients and in what type of patient it might be helpful for and how many strains and what strange those are but I think that in this study they actually gave micronutrients and they showed an increase in the diversity of the bacteria which many researchers will say you know even though we don't know exactly what type of bacteria probiotics might be helpful the end goal is to increase the diversity of bacteria in

7:04 the gut and that's a reflection of the how of a gut that's a more healthy I'm as far as adverse effects most kids tolerate them quite well if the if the kid is on medications there can be significant drug medication interactor should say medication nutrient interactions so that's a big big piece the micronutrients actually what they call can potentiate the effects of medications which means make them more strong or make them stronger so there's some definitely skill to learn about how to manage both of those things together but in the studies looking at just mono therapy with micronutrients the adverse effects were minimal and well tolerated there are

7:51 specific contraindications and these graphs are this table comes from the article written by Charles popper that I am showed earlier in the presentation and I think that they're becoming more and more accepted broad-spectrum micronutrients there was recently an article published in the psychiatric times also they had a podcast on the Charlotte report or the Karla podcast and there's a great TED talk on it as well so I think that we're seeing more and more press about this and as we get more studies especially as a second double Bible civil control trial for ADHD comes out in kids I think we're going to see even more about this there are two companies that that cell broad-spectrum eye curtain well there's several but that the two

8:36 main companies that sell them that have been researching this have their addresses down there for further information so I could speak about this for quite a long time but I'll pause there because there's many other things that we could talk about today Thank You Amelia any any questions or comments for Amelia on this topic and/or any other questions that might be on people's minds feel free to speak up or put them on the chat we use the broad spectrum micronutrients quite regularly in our clinics and and our fellows and residents can also share about their experiences with patients or with

9:23 themselves a lot of people are taking them and coming and telling me about their experiences you know just wondering what your go-to of the two major companies what do you usually prescribe you know what you know and what's the cost and yeah I'm happy to talk about those things so first of all I'll say a disclaimer is I have no financial interest in any of the companies in fact all the researchers doing research on the broad spectrum micronutrients do not get paid by the company so I think this is one of the it's a very cleanly studied intervention and dr. Bonnie Kaplan who's an amazing researcher speaks about the really the

10:09 fidelity of this work as far as what company I personally recommend I tell parents about both of them however most of the parents choose to go with a true hope because the dosage is twice daily as opposed to the D en which really needs to be according to the researchers needed needs to be dosed three times daily of note though the ADHD study that was they used to be one company and they actually they split several years ago so the the ADHD study was actually done with the de and product so I think that there are small differences between the two so that's a caveat to this as far as the price that's another reason I go with a

10:56 true hope because I think it's a little bit less there's the advanced formula and usually the dosage for like an eight or nine-year-old kid who's not is usually two twice a day or maybe three twice a day so in a latency age kids and maybe the teenagers maybe more like three twice a day or 3:00 in the morning 2:00 in the afternoon something like that and then the price I'd say depending on a bottle of 120 capsules is forty nine ninety five if you as a psychiatrist create a an account and then the then the patient will receive I think it's a 20% discount or thirty some twenty or thirty percent discount and I tell all my patients I don't make any money off

11:41 of this this is something that I'm just doing as a courtesy and so and part of the reason that they had that discount available to patients is that if the patient calls they're not going to give clinical advice to that patient if if they're under your account versus if they're just calling in and buying it there are people there that will help them navigate how much to take and etc and so were there any other questions you had was that where those so the question is from Becca have you been using the stimulants indicated for all children ADHD or just those you cannot tolerate stimulants no I use for both in my experience if a kid if a kid has still a lot of kids will

12:30 come to me maybe on like you know 54 of concerta and we'll still have dysregulated mood what we'll do is actually will start the micronutrients and usually we'll be able to bring that concerted dose about down to about half so we'll usually be able to bring it down to 36 or 27 and the kids are eating better which is great and they're needing less medication which is great and their mood is better and we do a cross titration so it actually has to be done kind of carefully and because kids can get worse right so if you're giving them the medication and the micronutrients there can be this potentiation and it can't get worse so I talked to parents a lot about that kind of having a sense of when that might happen having them check in and again this is just a short talk we've given like through the we've given lots

13:16 of talks about this so there's there certainly a nuance to it there is a chapter in this book here complementary and integrative treatments and psychiatric practice that we go into more that goes into more detail about it as well as machine might teach about it through the integrative psychiatry Institute that will does and the Andrew Weil Center for Integrative Medicine has a module on integrated mental health and we've done a section on broad spectrum there as well okay does so any insurance companies know that unfortunately don't reimburse it but like new she mentioned there are the HSA patients can by using their HSA card and Jesse also mentions so many kids who

14:03 tolerate taking the lightning stick initially because their parents make them but they don't like the powder or the taste then the parents get sick of the battles and let the kids stop and I suggest transitioning with the pills the family's pretty much done with the trial want to talk more want to talk more about meds any tips yes it is hard and this is what the research the Maddie's trials showed this as well but it's hard to get kids to stay on these it can be hard to get kids to stay on these because it's just a lot of pills so a couple of ways that we work on this is you can actually open the capsule and put it into yogurt or applesauce I find that really helps a lot of kids and families because I've tried it myself I personally can't taste it if it's an

14:50 apple sauce or yogurt and I use it personally as a multivitamin for my two-year-old and at a very very low dose and like half a capsule and I put it in her oatmeal applesauce and yogurt every morning and she has never complained about although she complains about many other different food choices so I think that's been a really powerful one and I think the other big piece to this is it doesn't it helps certainly ADHD mood dysregulation but it doesn't fix family dynamics and I think a lot of times we see kids with ADHD who also have comorbid OD D and so I think that certainly is a complicated factor it's not the end-all be-all of everything but I also notice over time we can decrease the amount of micronutrients

15:37 added dosage so usually a kid might need to twice a day in the beginning and then over time we can decrease it the other way you can decrease the dosage is if they start eating better and healthier so we talked about that as well what is Lydia asks what is your opinion of patching aspects of the broad-spectrum micronutrients by doing b-complex magnesium zinc often patients come in with their own combinations already excellent question here this one all the time I think that I think if they if I personally haven't had any success in patients doing that and I don't think that's where the Evan space really shows us as far as patch mailing them together I do see that I think that the big piece about is how the broad spectrum micronutrients are

16:23 chelated and it's chelated the chelation really affects the absorption so if they're just buying whatever thing over the counter we don't really know how much of that is being absorbed and I think that's the biggest piece in fact there was a recent study and I can send that to you looking at absorption and looking at chelation and amongst these different products Bonnie Kaplan said that to me recently there was this exact question on the Facebook group and that was her response so I'm happy and I'll put that in the chat box as well I've been able to have children take yes certainly you can if you could stick it into a smoothie that's great as well and nousheen also answered with broad-spectrum zark elated and better absorb and have research behind them it is crucial for children on the autism

17:08 spectrum to have supplements since they option refused eat vegetables yes and I see you know interestingly kids with kids who are on the autism spectrum as we know they respond very they are very sensitive to medications and you kind of got the have the dose exactly right I find of my clinical practice that for kids who are on the spectrum you know you're given them a stimulant near 10 milligrams too high or ten million five milligrams too high you see really difficult yeah and then if you switch it just a little bit things improved quite a bit and I see the same thing with micronutrients I had one kiddo who was taking for a day and we switched it to five and then all of a sudden there was a huge explosion of mood we switched it back down to four and things were a whole lot better so I've noticed specifically kids on the spectrum just

17:54 like they're sensitive to medication changes they can be sensitive to the micronutrient dosage Jana mentioned some of my struggles with the broad spectrum micronutrient specifically the sticks our parents thinking these are the same as emergency packets so they frequently let their children be in charge yes with the administration that I have yes I think that's a big piece you know a lot of times we think that vitamins are just you know take it when you want to and it tastes good or doesn't you know I think that we there is quite a bit of Education that into this as far as talking about how this is really an approach that has to be done judiciously I have a patient that I just saw the other day who is taking the lightning stick and you know sometimes at 8 a.m. and sometimes at 6 p.m. and then she took it at 6 p.m. she

18:41 couldn't sleep because there were B vitamins in there there were energizing for her so I do think that just like we talked about medication with risk benefits and alternatives um I certainly I have a handout that I gave to all the patients with all the TED talks on there and I really go through a lot of information with them so they understand this is a lar this is can be as effective as medication and it has a large effect size so we have to be careful with how we do this and I certainly talk document all the time this is a non FD or an off-label approach and has not so just for documentation reasons ok Bettina says if the family cannot afford true hope have you been able to get ncnc is that

19:26 Medicaid or Medicaid MCO manager managed care organizations thank you to have for any supplement I'll let nursing speak to that one I haven't had success but maybe machine yeah I already find it so my only success has been with HSA HSPs I know in New Zealand the the government has started to actually support the supplements as part of their insurance plans but not in the u.s. as far as I know and also question about how long do they have to do it it really depends on the health of that kid's own microbiome right so if the microbiome was it healthy they're gonna have a

20:12 harder time absorbing the nutrients so there might not be any effect unless you really address the microbiome and so there's some some art to that as well some I've seen kids respond as quickly as one day within a day on the lightening stick and the broad spectrums like an average kid I'd say with ADHD who's dysregulated who's on a stimulant I'd say about a week or two is usually when I noticed the improvement and I don't give up unless they unless they've been on it for about eight weeks six to eight weeks without an effect at that point I say okay let's try something different so we could speak on and on about this but I also wanted to make sure that there's time for anybody wanting to bring up issues around Integrative psychiatry in their

20:59 residency programs what people are doing if anyone has questions about what we're doing at the U of A wanting to open it up we really want to offer this as a forum for anybody who has questions about expansion of Integrative Medicine in academia Thank You Amelia and we can continue to respond to questions on chat but if anyone has any curriculum related comments or questions I would love to leave some room for that as Amelia said yeah go ahead Lydia I just want to say

21:46 just wanted to comment that I appreciated some of the free courses that have been available from University of Arizona recently and so we've put together kind of a document to our whole department on both the kind of self care free resources they're coming up from a lot of deleting organizations like academic consortium has put resources for providers and then you know Center for mind body medicine and our Center for spirituality the page and you know kind of tied those resources with opportunities to learn more about integrative medicine because so some of the you know as you're learning you're

22:32 also learning it for yourself so that's been really nice to have this so I want to thank you for that but especially as you know we have coronavirus and we had a comment from the residents particularly the ones that took over our course their first year in second years and now they're not impatient the remote there do some rounds remotely but they're finding themselves having a lot more free time and kind of itching to do things so this has actually been kind of opportunity for them as they put especially as we finish the quarters to offer these other options for them to continue the conversation and the learning thank you that's great yes I feel like these days my my volunteer job on the side is

23:18 posting and sharing for your resources it's nice to actually have resources to share yeah thank you for doing that it's just so nice to have a fingertips you know right I wanted to add something is it okay for you to comment on labs significant for Integrative Psychiatry and how some of those labs are not covered by insurance and how we can overcome this because I frequently had patients come in complaining oh my goodness my my lab bill is eight hundred

24:04 dollars or something like that absolutely so you know I think it's really important to code as many and diagnose these as comfortable to go with the labs so for example if you if you have a patient with generalized anxiety disorder and you order you know an entire slew of b12 and d and zinc and magnesium and all these different things that normally the current standards of practice do not include getting all of those labs for anxiety then the chances that the insurance company is going to send it back or charge them extra is a lot more however for the same patient if you add

24:49 chronic pain abdominal pain nausea dizziness diabetes autoimmune disorder headaches if whatever else you add to the code that go with the lab the chances that the insurance will cover are exponentially higher and I think that we see that all the time but I'm happy to hear from anyone else who's had experiences with insurance lab issues because I think a lot of times you know in integrative psychiatry we realized that we need these things because we care about the optimal functioning of the entire system however and unless you

25:35 really spell out a lot of these other symptoms and somebody's gonna find faults with why do you want to know what the RBC magnesium is you know if all they have is depression or whatever and they just don't get it but I think it also speaks to advocacy and how we need to continue to show the data that various micronutrient deficiencies do affect mental health but obviously that takes way longer for things to change on a policy level any other thoughts about that or anything else you

26:22 Betina for the children I see who are at risk of malnutrition or lead poisoning I can get laps covered and the ones that are adopted do you mean that Medicaid is easier on some of these issues versus private insurance or yes so so if you don't know the genetic background of the child then my argument with the insurance company get you know because it's to get the MCO to cover it is because it's part of the health benefit it's not the mental health benefit but it still is a health benefit if you don't know you know how their mitochondria is functioning you know the argument is maybe they are you know deficient in folate because you know

27:08 they have an inherited genetic defect so three adopted children I can get pretty much everything covered under both Medicaid and also you know medical assistance and even the private insurances how do you code so I for it that you know that they actually put down the you know we're trying to figure out would they need a mood stabilizer medication and if it's a mood stabilizer that's tegretol not that that would be my first choice for children but then they'll cover it because if you are you know folate deficient you're also gonna have a problem metabolizing tegretol and it could you know could kill you so you know they're basically brass tacks on that and you know let so late testing

27:56 that was actually harder so so for children in my practice who are not you know at risk of so the way it works in my area is they go by zip code so like they know the zip code your patient lives so they know if that's a hot area for lead poisoning or malnutrition you know food insecurity which leads to malnutrition so if they're not then I'll get back to rejection letters saying you know they don't want to pay for it so but if the shot if you can say that the child has Piko for example so I will like you know sometimes they really do like they are putting things in their mouths that are not you know so you know we know they're probably doing it for a psychological

28:41 reason this may not be a nutritional reason but hey hey I don't know so I want to know what's going on so that's how I've been able to get it paid cuz apparently for lead testing he generally they want to prove it for children over the age of three in my area they just have a blanket rule like that's how these insurance companies work they just have a rule for something and you know it's not individualized care it's just you know it's ridiculous thank you well thank you all for this very rich discussion take good care and stay in touch