A Word from Laura

I hope this newsletter finds you and your family well.  Here in the Midwest we have had a really cold winter with a lot of ice at times.  Fortunately, in the area where we live we have missed 4 or 5 large storms that dumped tons of snow.

This month I’m going to write about Dr. Ben Feingold’s work with hyperactive children 35+ years ago.   I’m in the process of writing an article for a medical journal about the “Feingold” Diet and what has been studied over the years, and I thought you, my reader, might be interested in what I’ve learned.  If you’re thinking the Feingold Diet was disproved years ago, I especially hope you’ll read on!

Good luck and best wishes,

Laura Stevens, M.S.

News for You

            The Feingold controversy began in 1973 when Benjamin Feingold, M.D., who was Chief Emeritus of the Department of Allergy at the Kaiser Permanente Foundation Hospital and Permanente Medical Group in San Francisco, was invited to present a paper to the American Medical Association annual meeting about his theory that hyperactive or hyperkinetic children were turned on by foods and food additives in their diet.  Prior to this point, Feingold was a well-respected allergist who had even published a textbook for doctors called, “Textbook of Clinical Allergy.” 

            How Feingold got to this point is interesting.  In his allergy practice at Kaiser Permanente he had a woman come to him for treatment of severe hives on her face and around her eyes.  What he didn’t know was that this woman was also seeing a psychiatrist for behavior problems but at that time psychiatric files were not passed with a patient’s regular medical chart.  So Feingold put the woman on the Kaiser Permanente Diet (“K-P Diet”).  Her hives quickly disappeared.  However, the psychiatrist called Feingold to ask what Feingold had done for the patient because her behavior was suddenly much better after 2 years of therapy that had accomplished little.  Intrigued by his patient’s response to the diet, he began to ask other patients about any psychological problems they might have and the effect of the K-P Diet on them.  Included in his patients were children diagnosed with “hyperkinesis,” “hyperactivity”—the disorder was renamed Attention Deficit Hyperactivity Disorder later on.  He was surprised to find that many of the hyperactive children improved on the K-P Diet.

            What is the K-P Diet?  Feingold had observed years before 1973 that his allergic patients who reacted to aspirin also were sensitive to foods containing natural salicylates which are similar in structure to aspirin.  Feingold and other allergists had also noticed that aspirin-sensitive patients commonly reacted to artificial colors and flavors.  So his diet eliminated the following:

            -All foods containing natural salicylates.  These included many nutritious foods  including apples, oranges, apricots, grapes, berries and cherries to name a few.

            -All foods containing artificial colors.  In the United States this included 2 blue dyes (brilliant blue, Indigotine), 2 yellow dyes (tartrazine and sunset yellow), 2 red dyes (erythrosine and allura red) and 1 green(fast green). On food labels they may be listed as US Certified Blue #1, Certified Blue #2, Certified Yellow # 5 and Yellow #6, Certified Red #3, Red #40 and Green #3.

            -All foods containing artificial food flavors which also had a salicylate group as part of the chemicals.  This included vanillin, the artificial form of vanilla.

            - Later Feingold added the preservatives BHA and BHT to his list of foods to be avoided which increased his success rate to 60-70 percent of the children he treated.

            At the AMA meeting, Feingold presented his hypothesis which sparked a lot of interest by the press, parents, and researchers.  He claimed that 30-50% of the problem children he had seen responded, often dramatically, to the K-P Diet.  The AMA sent Feingold around the country to talk about his success.  He also published a best-selling book, Why Your Child is Hyperactive.  About this time the Head of Purdue’s Food and Nutrition Department invited me to go to Ft Wayne IN to hear Feingold speak. He drew a large, very interested crowd for his presentation.   His presentation was excellent, but I often wondered if his personality interfered with acceptance of his theories.  A baby started to cry in the audience and he became furious that the mother had come with her child.  He was so insistent that he was right and no one else had any answers.  He was asked (by me) if wheat or milk could bother a child (I knew they could), and he responded that they didn’t contain salicylates so of course they couldn’t be problematic.  Although his message was very interesting, he seemed to turn some people off.  This was very unfortunate.

            Feingold was roundly criticized by medical, psychological, and nutritional experts.  They didn’t like the way he presented his information directly to parents without going through extensive well-designed studies published in medical journals.  His studies had used just Parent Rating Scales to assess behavior, but no control group or double-blind placebo-controlled study, and no statistics were ever presented.  He published his work but not in the most prestigious medical journals—Delaware Medical Journal, Ecology of Disease, and American Journal of Nursing. 

I can’t begin to tell you how Feingold’s efforts ticked off the establishment.  I once asked a pediatric neurologist at a major medical center about Feingold’s theories and he just laughed and said, “It’s just a fad.”  Years later he was still telling parents the same thing.  Even in our Foods & Nutrition Department at Purdue I bet 99% of the professors would agree today that the K-P Diet was just a fad without having reviewed any of the evidence–the same for doctors and psychologists.  Feingold died in 1982 so he didn’t live long enough to do the careful studies that he should have done in the first place!

            However, scientific studies did follow Feingold’s reports.  There were only a few studies of the K-P Diet as Feingold had outlined it.  These were difficult studies to carry out.  It was hard to come up with a control diet because many parents had read Feingold’s book or had seen him on television.  The K-P Diet was hard to follow and maintain and many families dropped out early.  But some children did seem to respond positively to the K-P Diet but not in the numbers Feingold had reported.   In many studies chocolate cookies were used to “hide” a mix of artificial colors.  However, later studies showed than many of these children were sensitive to chocolate itself!  Also the amounts of dyes were too low.

Do salicylate-containing foods trigger problem behavior?  There have been no studies of just salicylate-containing foods that I could find.  However, two studies gave aspirin tablets which is acetylsalicylic acid to hyperactive children who had responded positively to the Feingold diet in double-blind studies and many of the children reacted to the aspirin but not the placebo.  Whether that suggests that these children would also react to salicylates in natural foods is not known.

Do artificial flavors cause behavior changes?  I could find no study in the literature that gave artificial flavors without any other chemicals to children with ADHD.  So this is an unanswered question.

Do preservatives trigger behavior problems in hyperactive children?  By 1982 Feingold had included 2 preservatives—BHA and BHT—in the K-P Diet.  To my knowledge there have been no studies of those preservatives in ADHD children.  However, in a double-blind, placebo controlled trial one research group reported problems with calcium propionate, a preservative used in bread.  Some have suggested that sodium benzoate causes problems in sensitive children but there have been no good studies of this preservative by itself.

-Do artificial colors cause behavior changes in some hyperactive children?  The answer here is a definite “Yes.”  There have been many well-designed and controlled challenge studies of these dyes.  To see discussion of these articles, just type “artificial colors” or the author into the search box.  Here are their references:

• Swanson, JM and Kinsbourne, M. 1980.  Food Dyes Impair Performance of Hyperactive Children on a Laboratory Learning Test.  Science Vol. 207, pp 1485-1487.
• Salamy J et al.  1982.  Physiological Changes in Hyperactive Children Following the Ingestion of Food Additives.  International Journal of Neuroscience. Vol 16, pp. 241-246.
• Egger. J. 1985. Controlled Trial of Oligoantigenic Treatment in Hyperkinetic Syndrome. Lancet, vol. 1(8428) pp. 540-45.
• Carter, C. 1993.  Effects of a Few Food Diet in Attention Deficit Disorder. Archives of Diseases in Childhood 69, 1993, p. 564-568
• Boris, M. 1994 Foods and additives are common causes of attention deficit hyperactive disorder in children. Annals of Allergy vol 72, pp. 462-468.
• Uhlig, T.  1997.  Topographical mapping of brain electrical activity in children with food-induced attention deficit hyperkinetic disorder.  European Journal of Pediatrics vol. 156, pp. 557-561.
• Bateman, B. 2004.  The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity general population sample of preschool children. Archives of Diseases of Childhood vol. 89, pp. 506-511.
• B. Kaplan. Dietary replacement in preschool-aged hyperactive boys. Pediatrics 1989, pp. 7-17.

In 2004 Schab of Columbia University and Trinh of Harvard University, published a meta-analysis of previous artificial colors studies and behavior.  A meta-analysis is a statistical tool where the data from several studies—in this case 15–are analyzed together.  These scientists concluded that the hypothesis that artificial food colors promote hyperactivity in a subgroup of children with ADHD was strongly supported.

What about the question I asked Dr. Feingold—Can milk and wheat and other common foods that don’t contain salicylates trigger problem behavior in a subgroup of ADHD children?  The answer is a resounding, “Yes.”  Several “few foods diet” studies clearly show that these are common problem foods.  What researchers did was to put children with severe ADHD and other behavior problems on a very limited diet—two meats (lamb and chicken), two carbohydrate sources (potatoes and rice), two fruits (bananas and apples), vegetables and water.  Calcium and vitamins were supplemented.  In these studies about 70% of the children improved.  However, there was no placebo group.  Then foods were slowly added back to the diet one at a time and any reactions noted.  In the next phase offending foods and food additives were disguised in a “safe” food and reactions were observed.  Food dyes, chocolate, cow’s milk, oranges, eggs, wheat, and corn were common offenders.  Of these, only oranges contained salicylates.  You should not try this “few foods” diet unless you have support from your doctor and a dietician who can guide you.

In conclusion, perhaps Feingold’s greatest gift to research was the idea that foods and food additives could cause behavior problems in a subgroup of children with ADHD.  For more information about the Feingold diet, go to the Feingold Association’s website at www.feingold.org. This group publishes a very enlightening newsletter, “Pure Facts.” You will also find Jane Hersey’s book, Why Can’t My Child Behave interesting and helpful.  You’ll also like my book, 12 Effective Ways to Help Your ADD/ADHD Child published by Penguin Putnam.  You can order it on line or ask your bookstore to order it for you.  You can also borrow it free from your local library using Interlibrary Loan.