Non-pharmacological and Lifestyle Approaches to Attention-Deficit/Hyperactivity Disorder: 1. Diet

You can find some articles on Attention-Deficit/Hyperactivity Disorder (ADHD) here, and also some of the evidence that ADHD is a “real” illness and not just a label for socially unacceptable behavior. That being said, it is essential to take extra care when making the diagnosis. Mud sticks, and diagnostic mud sticks like glue. It can be hard to “unmake” a diagnosis.

As with any problem, the most effective way of helping it is to address the physical, psychological, social, subtle and spiritual aspects of the situation.

Medicines can definitely have a place in the management of ADHD, and the reason for treating ADHD is not so that people get better grades in school or do better at their jobs. It is to prevent the long term problems that may follow from inadequately treated ADHD.

There is a large and growing body of research on non-pharmacological approaches to treating ADHD. A literature search has turned up over two hundred papers, over half of which report some empirical research. Some of the research is summarized in a short paper aimed at health care professionals.

Research has shown that more than 50% of American families who receive care for ADHD in specialty clinics also use complementary or alternative medical (CAM) therapies, if you include things like modifying their diet or other aspects of their lifestyle. Despite that, only about 12% of families report their use of CAM to their clinician. Despite that low rate of families reporting the use of unorthodox therapies, a national survey of pediatricians showed that 92% of them had been asked by parents about complementary therapies for ADHD. The trouble is that many pediatricians have not been taught very much about the pros and cons of these approaches.

The most commonly used CAM therapies for ADHD are dietary changes (76%) and dietary supplements (> 59%). I have talked about food additives and one type of diet in the past. Now let’s look in a little more detail.

The 3 main dietary therapies for ADHD are:

• The Feingold diet,

• Sugar restriction, and

• Avoiding suspected allergens.

Sometimes these diets are used in combination.

The Feingold Diet
The Feingold diet is the most well known dietary intervention for ADHD. It aims to eliminate 3 groups of synthetic food additives and 1 class of synthetic sweeteners:
Synthetic colors (petroleum-based certified FD&C and D&C colors);

Synthetic flavors;

BHA, BHT and TBHQ ; and

The artificial sweeteners Aspartame, Neotame, and Alitame.

Some artificial colorings such as titanium dioxide are allowed.

During the initial weeks of the Feingold program, foods containing salicylates (such as apples, almonds, and grapes) are removed and are later reintroduced one at a time so that the child can be tested for tolerance. Most of the problematic salicylate-rich foods are common temperate-zone fruits, as well as a few vegetables, spices, and one tree nut.

During phase 1 of the Feingold diet, foods like pears, cashews, and bananas are used instead of salicylate-containing fruits. These foods are slowly reintroduced into the diet as tolerated by the child.

The effectiveness of this diet is controversial. In an open trial from Australia, 40 out of 55 children with ADHD had significant improvements in behavior after a 6-week trial of the Feingold. 26 of the children – 47.3% -  remained improved following liberalization of the diet over a period of 3-6 months.

In another study, 19 out of 26 of children responded favorably to an elimination diet. What  is particularly interesting is that when the children were gradually put back on to a regular diet, all 19 of them reacted to many foods, dyes, and/or preservatives.

In yet another study, this one a double-blind, placebo-controlled food challenge in 16 children, there was a significant improvement on placebo days compared with days on which children were given possible problem foods. Children with allergies had better responses than children who had no allergies.

Despite this research many pediatricians, particularly in the United States, do not believe the evidence regarding the effectiveness of elimination diets or additive-free diets warrants this challenging therapy for most children.

There is an interesting difference in Europe. In 2004 a large randomized, blinded, cross-over trial of over 1800 three-year-old children was published. The results showed consistent, significant improvements in the children's hyperactive behavior when they were on a diet free of benzoate-preservatives and artificial flavors. They had worsening behavior during the weeks when these items were reintroduced. On the basis of this and other studies, in 2004 schools in Wales banned foods containing additives from school lunches. It has been claimed that since the ban, there has been an improvement in the afternoon behavior of students.

The biggest problem with the Feingold and other elimination diets is that they are hard to follow and to maintain. But for some children and families, the inconvenience and stricter attention to food have worthwhile results.

It is also essential to ensure that children on any kind of diet maintain adequate nutrition: there have been many examples of that simple rule not being followed.

Sugar Restriction
The notion that sugar can make children “hyper” entered the mainstream over twenty years ago, and is now on the list of things that “everyone knows.” But happily it is not true. At least 12 double-blind studies have failed to show that sugar causes hyperactive behavior. Some researchers suggest that sugar or ingestion of high-carbohydrate "comfort foods" is actually calming, and that children who seek these foods may be attempting to "self-medicate."

There are plenty of very good reasons for children to avoid candy, but hyperactivity is not one of them.

Food Allergies
There is clear evidence that children, and perhaps adults with ADHD are more likely to have allergies. That lead to the obvious question whether children with ADHD allergic or sensitive to certain foods. (It is useful to differentiate “allergies” that are the result of abnormal reactivity of the immune system to proteins in food, from “sensitivities” that are the direct result of substances in food: the two have different treatments.)

It is certainly true that food allergies and food sensitivities can generate a wide range of biological and behavioral effects. Gluten sensitivity (celiac disease) is known to be linked to an increased risk of ADHD and other symptoms.

In an open study of 78 children with ADHD referred to a nutrition clinic, 59 improved on a few foods trial that eliminated foods to which children are commonly sensitive. For the 19 children in this study who were able to participate in a double-blind cross-over trial of the suspected food, there was a significant effect for the provoking foods to worsen ratings of behavior and to impair psychological test performance.

For more than 30 years one of the tests used to track allergies has been the radioallergosorbent test (RAST). It is not much used these days since technology has moved on. In an allergy testing study of 43 food extracts 52% of 90 children with ADHD had an allergy to one or more of the foods tested. Over the next few years several researchers carried out open-label studies in which children with ADHD and food allergies were treated with a medicine called sodium cromoglycate, that prevents the release of inflammatory chemicals such as histamine from mast cells. Some of the reports suggested that it could help in some children.

Other popular dietary interventions include eating a low glycemic index diet to avoid large swings in blood sugar. Another strategy has been to “go organic” to reduce the burden of pesticides, hormones, antibiotics, and synthetic chemicals in the child's system. These diets need more scientific study but they are probably safe if expensive.

There are plenty of practitioners and commercial entities who claim to be able to identify food sensitivities with all kinds of methods from blood and muscle testing to electrical and energetic techniques. Some may be helpful, but few have been proven to be effective.


What Should Parents do About Diet, Nutrition, Allergies and Sensitivities?
It is very difficult to predict whether an individual child will be helped by changes in diet. However, as long as the child’s needs for essential nutrients are met these diets should be safe.

It is an extremely good idea for parents to keep a diet diary for one to two weeks to see if anything obvious jumps out. Then trying an additive-free diet, low in sugar and avoiding foods that are suspected of exacerbating symptoms. You will normally find the answer - yes or no - within a few weeks.


What is the Evidence for Food Sensitivities and ADHD in Adults?
Not a lot!

There are plenty of people who have reported that dietary restrictions have helped them, but there is very little evidence. One of the problems about looking for food sensitivities is that there is a high placebo response rate. But if you have adult ADHD, it may be worth investigating. Just make sure that any diet that you use is nutritionally sound. And if you don't find anything reconsider another approach.

Comments

[Craig]

Richard,

We have a 7-year old daughter with Asperger Syndrome (Aspergers is an autism-spectrum disorder that shares some symptoms with ADD/ADHD individuals).

Three years ago, we tried the Feingold Diet treatment and have had good success with it helping her attention span, anxiety, and general outbursts.

However, my wife and I found it somewhat difficult to find many of the Feingold-accepted foods, so we created The Asperger's Store at www.aspergerstore.com, which lists all the Feingold-accepted foods which Amazon.com carries.

Hopefully, this list will be of some help to others who read your blog.

Craig

[Richard Petty]

Dear Craig,

Thank you so much for writing.

I am delighted to hear that the Feingold Diet helped your daughter. As you discovered, it can be a bear to follow it.

I have looked at your website and I am more than happy to publicize it.

It is well constructed and I like your balanced approach to the products that you carry.

I wish you, your family and your clients the very best of health.

Kind regards,

RP

[Jane Hersey]

There is an inaccuracy in your web site. You write: "The biggest problem with the Feingold and other elimination diets is that they are hard to follow and to maintain."

Dear Dr. Petty,

Thank you for your attention to detail as you write about some of the studies that deal with diet and ADHD. However, you share a common misconception with many others -- that it is difficult to follow the Feingold diet. If a parent were to try to do this on their own it could be difficult, this is why we formed a support group and why we research brand name products and publish books listing thousands of acceptable foods. [Our database contains over 11,000 products.]

We also research non-food products, some medications and fast food.

This list of products is intended to be used by the newcomer, so they can run a fairly pure trial to see if our program will help. Once they have gained some experience most families find they can add in many additional brand name foods and make educated choices.

Some of the products that are being successfully used by Feingold families include: Duncan Hines Dark Chocolate Fudge Cake Mix, Kraft White Cheddar Macaroni & Cheese Mix, Natural Cheetos, Natural Doritos,
Coca Cola, Big Macs, Subway sandwiches, Einstein Bagels, Domino's Pizza, Arby's Roast Beef sandwich, Ghirardelli Chocolate candy bars, SunRidge Farms natural jelly beans, Kellogg's Crispix, Hershey's Cocoa, Welch's Grape Juice, Minute Maid Orange Juice, Post Raisin Bran, Heinz Ketchup, Fritos Corn Chips, Minute Rice, Hellmann's Mayonnaise, Land O Lakes Butter, Kraft Philadelphia Cream Cheese, Aunt Jemima Easy Mix Coffee Cake, Breyer's Vanilla Frozen Yogurt, Breyer's Natural Ice Cream, Chicken of the Sea Tuna, Louis Rich Luncheon Meat, Oscar Meyer Luncheon Meat, Planter's Nuts, most brands of rice, noodles and pasta, Jiffy Pop Popcorn, etc.

Craig's family uses the Feingold Program, but they have also added a gluten-free diet, which is very difficult to follow; his web site offers some of the products that are both Feingold-acceptable and gluten free. Unfortunately, his message to you gave the impression that the Feingold diet is restrictive, which it is not.

Many people misunderstand the Feingold diet, believing that it cuts out sugar, or chocolate, or requires one to buy only organic foods. We encourage them to visit our web site at www.feingold.org to get accurate information.

Please consider taking a closer look at our work and editing the comments on your site.

Thank you,
Jane Hersey, Director
Feingold Association of the US