ADHD AND THE DEMONIZATION OF FOOD: THE SHORT, UNHAPPY HISTORY OF

ELIMINATION DIETS FOR THE TREATMENT OF ADHD

FRANCIS M. CRINELLA, PH.D.

PROFESSOR OF PEDIATRICS, PSYCHIATRY & HUMAN BEHAVIOR, AND PHYSICAL MEDICINE & REHABILITATION

DIRECTOR, NEUROPSYCHOLOGY LABORATORYCHILD DEVELOPMENT CENTER

UNIVERSITY OF CALIFORNIA, IRVINE

11 JANUARY 2012

ELIMINATION DIETS AND MENTAL DISORDERS

“BOTH THE QUALITY AND QUANTITY OF ALIMENT HAS AN INFLUENCE UPON MORALS, A MILK AND VEGETABLE DIET IS RECOMMENDED BECAUSE OF THE EFFICACY OF A VEGETABLE DIET UPON THE PASSIONS.”

BENJAMIN RUSH, ADDRESS TO, 1786THE AMERICAN PHILOSOPHICAL SOCIETY

ELIMINATION DIETS AND ADHD

Why your child is hyperactive.

Benjamin F. Feingold

Random House, New York (1973).

5

ELIMINATION DIETS AND ADHD

Hyperkinesis and Learning Disabilities Linked to the Ingestion of ArtificialFood Colors and Flavors

Ben F. Feingold, M.D.

AMERICAN ACADEMY OF PEDIATRICS

November 8, 1977

1. ANY COMPOUND IN EXISTENCE, EITHER NATURAL OR SYNTHETIC, HAS THE CAPACITY TO INDUCE AN ADVERSE REACTION IN ANY INDIVIDUAL WITH THE APPROPRIATE GENETIC PROFILE.

2. COLORS AND FLAVORS ARE THE MOST PERVASIVE ADDITIVES IN OUR FOOD SUPPLY, INVOLVING ABOUT 80% OF OUR FOODS

3. COLORS AND FLAVORS ARE THE COMMONEST CAUSE OF ADVERSE REACTIONS.

4. COLORS AND FLAVORS HAVE NO NUTRITIONAL VALUE.

B. F. Feingold (1977)

FEINGOLD (CONT’D)

THE KAISER-PERMANENTE (K-P) DIET:

1. ELIMINATE ALL FOODS WITH ARTIFICIAL COLORS AND FLAVORS

2. ELIMINATE ALL FOODS WITH THE ANTIOXIDANT PRESERVATIVES BUTYLATED HYDROXYTULENE (BHT) AND BUTYLATED HYDROXYANISOLE (BHA)

3. ELIMINATE SELECTED GROUP OF FOODS CONTAINING A NATURAL SALYCYLATE RADICAL (E.G., APPLES)

Results of K-P Diet studies

0

10

20

30

40

50

60

70

80

90

100

Levy1978

Egger1983

Egger1985

Rowe1988

Egger1989

Kaplan1989

Carter1993

Boris1994

Rowe1994

Pelsser2002

Percent ofchildrenimproved

FEINGOLD (CONT’D)

THE MODE OF DISCOVERY OF THE K-P DIET

1. FEINGOLD WAS A PEDIATRIC ALLERGIST.

2. INITIALLY HE OBSERVES THAT IN THE MANAGEMENT OF VARIOUS ALLERGIC COMPLAINTS, SUCH AS ECZEMA, THERE WAS ALSO FAVORABLE IMPROVEMENT IN THE CHILD’S BEHAVIOR (“REDUCED HYPERKINESIS, AGGRESSION AT HOME AND SCHOOL, CONFLICT WITH PEERS, FAILING AT SCHOOL, AND NEED FOR BEHAVIOR MODIFYING MEDICATIONS”).

3. “TODAY, WITH THE ELIMINATION OF BHT AND BHA, THE SUCCESS RATE FOR THE K-P DIET IN CONTROL OF BEHAVIOR IS BETWEEN 60 TO 70 PERCENT.”

STEP 1: RECRUIT A GROUP OF CHILDREN DIAGNOSED WITH ADHD

STEP 2: REMOVE ALL ADDITIVES FROM DIET

STEP 3: “70% WILL IMPROVE”

STEP 4: INTRODUCE CHALLENGE WITH AFC TO 70% WHO RESPONDED FAVORABLY TO ELIMINATION DIET

15

How much to use?

16

Challenge studies

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Percent ofchildrenreacting tofood dyechallenge

%

Levy(a) Sarantinos Pollock Adams Swanson Goyette Swanson Rowe Wilson Rowe Weiss Harley Levy(b) Spring(a) Spring(b) 1978 1990 1990 1981 1980 1978 1980 1988 1989 1994 1980 1978 1978 1981 1981

SWANSON AND KINSBOURNE, 1980

STUDY DESIGN

40 CHILDREN, 20 WITH ADHD AND 20 WITHOUT ADHD

DURING INPATIENT STAY, K-P DIET INTRODUCED FOR 3 DAYS

ON DAYS 4 AND 5, 20 CHILDREN RECEIVED CAPSULES CONTAINING BLEND OF NINE (9) FOOD DYES, AND 20 CHILDREN RECEIVED PLACEBO (SUGAR PILL) AT 10 AM

THE CAPSULE CONTAINED 150 MG OF FOOD DYES [FDA ESTIMATES THAT THIS WAS AT THE 90TH %ILE FOR DAILY CONSUMPTION BY CHILDREN] CHILDREN WERE TESTED ON PAIRED ASSOCIATES LEARNING TEST AT 0930, 1030, 1130 AND 1330.

FOOD DYES IMPAIR PERFORMANCE OF HYPERACTIVE CHILDREN ON A LABORATORY LEARNING TEST.

SWANSON, J.M. & KINSBOURNE, M. SCIENCE, 207, 1485-1486 (1980)

SWANSON AND KINSBOURNE, 1980 (CONT’D)

9:30 AM 10:30 AM 11:30 AM 1:30 PM

MORE ERRORS

8 10 16 17

NO MORE ERRORS

12 10 4 3

TABLE INDICATING WHETHER CHILDREN MADE MORE OR NO MORE ERRORS ON PAIRED ASSOCIATES LEARNING TESTS AFTER RECEIVING PILL WITH ARTIFICIAL FOOD COLORING

NOTE: PILL WAS INGESTED AT 10:00 A.M.

FEINGOLD REPORTED THIS STUDY AS SHOWING THE MORE THAN 80% OF CHILDREN REACTED UNFAVORABLY TO FOOD DYE CHALLENGE

SWANSON AND KINSBOURNE, 1980 (CONT’D)

DATA GRAPHED SHOWING ACTUAL NUMBER OF ERRORS MADE BY EACH GROUP UNDER EACH CONDITION (FOOD DYE PILL OR PLACEBO)

SWANSON & KINSBOURNE STUDY (2000)

ON AVERAGE, ADHD CHILDREN, AFTER TAKING A CAPSULE EQUIVALENT THE 90TH PERCENTILE OF AFC CONSUMPTION AMONG U.S. CHILDREN, MADE ABOUT 10 MORE ERRORS THAN WHEN THEY WERE ON PLACEBO

THE AFC CAPSULE APPEARED TO HAVE NO EFFECT ON NON ADHD CHILDREN

BUT: PARENT AND TEACHER RATINGS ON THE CONNERS ADHD RATING SCALE WERE ALSO FILLED OUT 2 X DAILY.

AND: THERE WERE NO SIGNIFICANT DIFFERENCES BETWEEN THE AFC AND PLACEBO CONDITION ON EITHER THE TEACHERS OR THE PARENT RATINGS

FOOD ADDITIVES AND HYPERACTIVE BEHAVIOR IN 3-YEAR-OLD AND 8/9-YEAR-OLD CHILDREN IN THE COMMUNITY: A

RANDOMIZED, DOUBLE-BLINDED, PLACEBO-CONTROLLED TRIAL

McCann et al, Lancet, September 6, 2007THE STUDY:

THREE YEAR-OLDS (N = 153) AND EIGHT AND NINE YEAR OLDS (N – 144)

RANDOMLY ASSIGNED TO:

GROUP A. DAILY DRINK WITH ARTIFICIAL FOOD COLORING IN AMOUNT TYPICAL TO THAT CONSUMED BY AVERAGE CHILD IN ONE DAY

GROUP B. DAILY DRINK SIMILAR IN TASTE AND APPEARANCE TO GROUP A DRINK BUT WITHOUT ARTIFICIAL FOOD COLORING

AFTER TWO WEEKS, GROUPS “CROSSED OVER” FOR ANOTHER TWO WEEKS

McCann et al, Lancet, September 6, 2007 (CONT’D.)

THE MEASURES OF HYPERACTIVITY:

1. ABBREVIATED [10 ITEM] CONNERS ADHD RATING SCALE (TEACHER; WEEKLY)

2. WEISS-WERRY-PETERS HYPERACTIVITY SCALE (PARENTS; WEEKLY)

1. SWITCHING ACTIVITIES

2. INTERRUPTING OR TALKING TOO MUCH

3. WRIGGLING

4. FIDDLING WITH OBJECTS OR OWN BODY

5. RESTLESS

6. ALWAYS ON THE GO

7. POOR CONCENTRATION

3. 3 WEEKLY 8-MINUTE CLASSROOM OBSERVATIONS BY GRADUATE STUDENT ASSISTANTS, RATING CHILDREN FOR “ON TASK” VS. “OFF TASK” BEHAVIOR

McCann et al, Lancet, September 6, 2007 (CONT’D)

RESULTS:

DRINK WITH ARTIFICIAL FOOD COLORING HAD A STATISTICALLY SIGNIFICANT EFFECT ON BEHAVIOR THREE YEAR-OLDS (N = 153) AND EIGHT AND NINE YEAR OLDS (N – 144) WHEN CONTRASTED WITH THE EFFECTS OF THE PLACEBO

THE EFFECT SIZE WAS A DEPARTURE OF 0.18 STANDARD DEVIATIONS FROM THE MEAN.

A DEPARTURE OF 2.0 STANDARD DEVIATIONS FROM THE MEAN IS REQUIRED FOR THE CLINICAL DIAGNOSIS OF ADHD.

McCann et al, Lancet, September 6, 2007 (CONT’D)

PUBLIC POLICY OUTCOME:

1. EUROPEAN UNION MAKES DECISION TO ADD A WARNING LABEL ON FOODS CONTAINING ARTIFICIAL FOOD DYES:

“THIS FOOD MAY HAVE AN ADVERSE EFFECT ON ACTIVITY AND ATTENTION IN CHILDREN”

2. HEARINGS CONDUCTED BY U.S. FDA IN MARCH, 2011. AT THE END OF THE TWO DAY MEETING, THE FDA VOTED TO TAKE NO ACTION ON CURRENT U.S. USE OF FOOD DYES.

79% OF COMMITTEE VOTED THAT NO ACTION SHOULD BE TAKEN

GRAPHIC REPRESENTATION OF McCANN ET AL FINDINGS IN TERMS OF NORMAL CURVE EQUIVALENTS

McCANN EFFECT

ADHD DIAGNOSTIC THRESHOLD

CONCLUSIONS FROM FDA COMMITTEE MEETINGS A SMALL NUMBER OF CHILDREN APPEAR TO BE HYPERSENSITIVE TO FOOD AND WHO ARE ALSO DIAGNOSED WITH ADHD MAY RESPOND WELL TO A DIET ELIMINATING THE FOODS TO WHICH THEY SHOW AN ALLERGIC REACTIONS

IF A CHILD WITH ADHD’S BEHAVIOR BECOMES PERCEPTIBLY WORSE WHEN CONSUMING ANY PARTICULAR FOOD, CONSIDER AVOIDING THAT FOOD, ALTHOUGH DOING SO WILL NOT ELIMIINATE ADHD

SOMETIMES, ELIMINATING A PREFERRED FOOD MAY CAUSE EMOTIONAL REACTIONS THAT WILL MAKE ADHD SYMPTOMS WORSE THAN ANY POSSIBLE CONTRIBUTION FROM THE FOOD

A HEALTHY DIET IS IMPORTANT FOR ALL CHILDREN, INCLUDING CHILDREN WITH ADHD

NON-PHARMACOLOGICAL INFLUENCES ON 5-HT

In the Golub laboratory at the University of California, Davis, we have also shown that over-absorption of dietary manganese (Mn) not only affects brain 5-HT levels, but also results in aggressive and impulsive behavior of rhesus monkeys

ADHD IS ONE OF THE MOST COMMON DISORDERS OF CHILDHOOD

•ACCOUNTS FOR AS MANY VISITS TO PEDIATRICIANS AS UPPER RESPIRATORY INFECTIONS

•CHARACTERIZED BY A PERSISTENT PATTERN OF OVERACTIVITY, INATTENTION, AND IMPULSIVITY

•WORLDWIDE PREVALENCE IS ESTIMATED AT 5% ±3%

•RELATED TO DYSFUNCTION IN THE BRAIN’S DOPAMINE NETWORKS

STIMULANTS (E.G., RITALIN; DEXEDRINE), WHICH ARE DOPAMINE AGONISTS, ARE THE MOST EFFECTIVE KNOWN TREATMENT FOR ADHD--

BUT:

1.STIMULANTS HAVE NOT BEEN UNIFORMLY EFFECTIVE IN MODIFYING ADHD SYMPTOMS, WITH ESTIMATES OF NON-RESPONDERS RANGING FROM 25 TO 35%

2.STIMULANT DRUGS, IRRESPECTIVE OF THEIR EFFICACY IN TREATING ADHD SYMPTOMS, ARE NOT WITHOUT SIDE EFFECTS, SUCH AS ANOREXIA, INSOMNIA, AND REDUCED GROWTH RATE

3.EVEN IF STIMULANTS WERE 100% EFFECTIVE, WITH NO SIDE EFFECTS, SOME FAMILIES REMAIN UNALTERABLY OPPOSED TO TREATING THEIR CHILD WITH PRESCRIPTION DRUGS.

AT THE TME OF FIRST CONTACT WITH THE UCI CHILD DEVELOPMENT CENTER, 60% OF FAMILIES WILL HAVE TRIED COMPLEMENTARY AND ALTERNATIVE MEDICINES (CAMs), INCLUDING:

•COGNITIVE BEHAVIORAL THERAPY

•NEUROFEEDBACK • AEROBIC EXERCISES

•HERBAL REMEDIES

•ELIMINATION DIETES (THE MOST COMMON BEING REFIEND SUGAR, AT 31%)

•DIETARY SUPPLEMENTATION (vitamins, minerals, fatty acids; alone or in various combinations)