By Michael Jacobson
Issue 101, July/August 2000
In the early 1970s, Dr. Benjamin Feingold, then chief emeritus of the Department of Allergy at the Kaiser Foundation Hospital and Permanente Medical Group in San Francisco, reported a link between diet and several physical and allergic conditions. Thirty to 50 percent of Feingold's hyperactive patients said they benefited from diets free of artificial colorings and flavorings, and certain natural chemicals (salicylates, found in apricots, berries, tomatoes, and other foods).
Although many parents eagerly embraced the Feingold diet, others--such as the processed-food industry, many child-behavior experts, and some pediatricians--were more skeptical. Perhaps, they reasoned, the families were doing other things in addition to dietary modification, or maybe they were simply reacting to wishful thinking. With time, however, researchers began testing aspects of Feingold's claim. Over the following decades, almost two dozen additional controlled trials followed, mostly focusing on food dyes. In some cases, children were put on a diet that lacked many food additives and subsequently "challenged" with dyes. In other cases, the behavior of children was monitored after they were switched to a diet free of certain foods that might cause a reaction (dyes, wheat, egg, chocolate, and others) and then challenged with those foods. Most--but not all--of those studies found that some--but not all--children were affected by diet, some slightly, others dramatically.
In 1982, the National Institutes of Health (NIH) convened a "consensus development conference" on diets and hyperactivity to review the early scientific research and advise health professionals and the public. Their conclusion was that controlled studies "did indicate a limited positive association between. . . [Feingold-type] diets and a decrease in hyperactivity." The panel recommended further broad research on the diet-behavior connection--advice that generally has not been heeded. This is in part why so little is known today about the percentage of children who respond to dietary therapy, to what degree they respond, which children are most likely to be affected, the additives and foods that cause problems, and the best ways to use diet therapy.
Nevertheless, in the face of ever-escalating Ritalin prescriptions, some families are seeking out dietary therapy for their children. One reason for their interest is that Ritalin and amphetamines (such as Adderall and Dexedrine) may cause reduced appetite and weight loss, stomachaches, and insomnia. More seriously, those drugs occasionally may cause or exacerbate tics and Tourette's syndrome. Another drug, Pemoline (Cylert), has been associated with fatal liver failure; the Food and Drug Administration (FDA) urges doctors not to use it to treat ADHD.
Furthermore, until long-term studies are done, it will not be known whether years-long treatment in childhood (or, for that matter, adulthood) with stimulant drugs has an effect on the nervous system or other parts of the body later in life. Importantly, a study by the federal government's National Toxicology Program (NTP) found that doses of Ritalin that only modestly exceeded the maximum recommended dose in humans caused liver tumors in mice. "Millions of young children take Ritalin for years on end, and children may be especially susceptible to a carcinogen's effects," says Samuel Epstein, a cancer expert at the School of Public Health at the University of Illinois. Although the NTP study indicates "a weak signal of carcinogenic potential," the government still considers the drug safe. Yet the lack of a long-range study of Ritalin's possible carcinogenic effect is extremely troubling. Large numbers of children have been consuming Ritalin for only the past one or two decades, and cancer might not manifest itself for several decades later in life.
Trying a Dietary Modification Approach
Parents wishing to test their children's response to diet will seek to identify and remove irritants in foods (and other products) that cause behavioral symptoms. This is done by eliminating certain foods (and vitamins and drugs) from the (unmedicated) child's diet for several weeks to see if his or her behavior is improved. In some cases, dietary changes by themselves may adequately reduce behavioral problems. If not, amphetamines or another medication could be tried in addition to, or instead of, a restricted diet. The goal is to identify the specific foods or additives, if any, that affect your child. What makes this challenging is that children's behavior ordinarily is so variable.
Needless to say, controlling the diets of young children can be difficult, especially once children go to school. Foods containing dyes and other potentially provoking ingredients are advertised aggressively and available everywhere: at supermarkets, restaurants, schools, vending machines, parties, theaters, and the homes of friends and relatives. Many young children are already "hooked" on the very foods that may cause problems, though it is getting easier to find acceptable alternatives. And children who don't eat what all their friends eat may feel left out or stigmatized.
Some parents who've put their children on special diets, though, say their children willingly cooperate in making dietary changes, especially after they discover that those changes make them feel better. Some older children avidly read labels to avoid certain ingredients.
Although some studies suggest dietary therapy can be more effective among young (preschool) children and those who suffer from asthma, eczema, hives, hay fever, or similar symptoms, a diet could be worth trying no matter how old your child is or how the behavioral problem is manifested. It is certainly safer and cheaper than using stimulant drugs, and, if your child has been eating a lot of artificially colored foods, it may also be more nutritious.
Numerous studies have demonstrated that some children are sensitive to dyes. Thus, you might start by eliminating only foods (and vitamins, drugs, and toothpastes) that contain artificial colorings. The Feingold diet eliminates additional additives, as well as "salicylate-containing" foods. That diet eliminates: artificial colorings (look for names like "Red 40" and "Yellow 5" on labels)
artificial flavorings (including vanillin, used in synthetic vanilla)
artificial sweeteners (acesulfame-K, aspartame, saccharin, sucralose)
BHA, BHT, and TBHQ preservatives
One study suggests that sodium benzoate and benzoic acid should also be on that list. The Feingold diet also excludes certain fruits and vegetables, although studies have not demonstrated that they cause problems. (See "Sidebar: Foods on the Feingold Diet"). While that diet excludes many common foods, you can later reintroduce any to which your child is not sensitive.
Once you have decided which foods and additives you will eliminate, check out all the foods in your refrigerator, pantry, and cupboards, and remove or discard any that contain banned ingredients. Do not forget restaurants: many fast-food chains offer lists of the ingredients in their products; ask servers or call their consumer-affairs offices. The Feingold Association publishes lists of selected packaged and chain-restaurant foods that fit into the diet, but you will have to become a careful label reader and inquisitive restaurant-goer to learn the ingredients in your children's favorite foods. It may be easier to stick to home-prepared meals during this test period.
Once you are set to go, put your child (and the rest of the family, if possible) on the modified diet for two or three weeks. If your child mistakenly eats a prohibited food, do not get upset--just get him or her back on the diet. Using a separate page for each day, keep a score sheet (click here for sample score sheet) based on common characteristics of ADHD, but modify that to include your own child's most troubling behaviors. Note when behavior problems arise and which foods your child had eaten recently. Engage your child's teacher in monitoring your child's behavior, but unless the teacher provides snacks for your child, there is no reason to risk drawing attention to your young one by telling the teacher about the diet.
Next, you can try eliminating more of the additives or foods suspected of affecting behavior. Likewise, if your child's behavior did not improve on the initial diet, it could mean that he or she is not affected by foods at all or is sensitive to other foods. It's also possible that prohibited ingredients are sneaking into your child's diet.
The "Few-Foods" Diet
If your child's behavior did not improve on the Feingold diet, you could try a more restrictive "few-foods" diet. Studies indicate that some children are sensitive not just to food additives but also to such foods as the following:
milk and other dairy foods
corn products (including corn sugar and syrup)
On this diet, eliminate as many of those foods as you can, as well as artificial colorings and other additives. Children can eat fresh meat and poultry, any vegetable (except corn and soybeans), fruits and fruit juices (but not citrus fruit juice and not beverages normally consumed daily), rice, and oats. Work with an allergist if you undertake an elimination diet, especially if your child has eczema or other allergies. (Severe reactions might occur when a food is reintroduced.) The more foods you eliminate, the more complicated it will be to provide healthy meals and win your child's cooperation. Fortunately, most of the restrictions will be temporary, because you will be trying to identify the foods that do not cause problems, as well as those that do.
Keep your child on the few-foods diet for two weeks, tracking his or her behavior until you notice two consecutive days of significantly improved behavior. Note that it can be difficult to distinguish an effect of diet from your child's normal fluctuations in behavior. If you don't notice any improvement, you can end your experiment.
If you have noted improved behavior, reintroduce one of the eliminated foods or additives at a time. After your child has eaten that food for several consecutive days, note in your diary any symptoms that develop. If that food did not affect your child, then consider it safe to eat. If your child's behavior deteriorated, exclude that food from your child's diet, or retest it again later. Every few days reintroduce another food and keep track of how your child reacts. Gradually, you may be able to identify foods that do and do not affect your child.
If your child stays on a very restricted diet for more than a few weeks, you should work with a dietician to plan meals that provide all the nutrients your child needs. Also, your child should take a daily vitamin-and-mineral supplement, which may make sense regardless of what diet he or she is on.
Another approach is to feed your child the few-foods diet until you see an improvement. Then reintroduce everything--dyes, wheat, the works--for several days to see if anything triggers a reaction. If your child's behavior worsens, return your child to the special diet and reintroduce foods one by one until you find the problems.
Finally, do not expect diet to bring about miraculous improvements in behavior. Even in kids who are affected by food ingredients, eliminating the culprits often yields only a partial improvement. But even partial improvements could be most welcome. If your child does not benefit significantly from a restricted diet, you should discuss with your pediatrician other treatment options, including medications and behavioral counseling.
Whether or not your child has behavioral problems, he or she should eat a nutritious diet. Most children eat far too many fatty, salty, and sugary foods-from burgers, fries, cheese, and ice cream to soft drinks, potato chips, and candy. And few children get the vitamins, minerals, fiber, and phytochemicals they need from fruits, vegetables, and whole grains. It is important to your child's current and future health to eat a really healthful diet (and that may mean that you need to improve your diet to set a good example!).
First steps include getting rid of the junk foods in your home, making fatty and sugary foods off-limits when eating out, and turning off television shows riddled with junk-food ads. Also, give your child a daily vitamin-and-mineral supplement.
FOR MORE INFORMATION
Center for Science in the Public Interest
1875 Connecticut Avenue NW, Suite 300, Washington, DC 20009
Center for Science in the Public Interest
Box 70373 Toronto Station A, Toronto, ON M5W 2X5
Feingold Association of the United States
PO Box 6550, Alexandria, VA 22306
Michael Jacobson is executive director of the Center for Science in the Public Interest (CSPI, a nonprofit health-advocacy organization). The contents of this article are not intended to provide personal medical advice, which should be obtained from a qualified health professional.