HYPERACTIVITY REVISITED
by
Theodore E. TePas, MD

In June, 1973, Benjamin Feingold, MD, first proposed that artificial colors and flavors might affect children’s behavior.1 The scientific and medical community didn’t exactly embrace this idea, and a number of studies followed.

". . . several studies on single cases and groups of children have shown that artificial colors produce interference with learning and performance."

The first study to receive any significant publicity was the double-blind study done in 1978 by Harley et al., supported be the University of Wisconsin’s Food Research Institute.2 Based on the parents’ rating, there appeared to be a significant effect in favor of the control diet and not the experimental "Feingold Diet." The end result was that there was a basic lack of data to support Feingold’s hypothesis. Other studies followed.3,4 Then in 1979, at the Hospital for Sick Children in Toronto, Swanson and Kinsbourne5 followed the lead of Sobotka6 of the FDA, who reported in a July 1976 memo the intake of food colors for the highest 10 percent of 1-to-5 year olds at 121.3 mg/day. In the Toronto study, on 100 mg/day of the dye tartrazine (FD&C Yellow no. 5) there was a 34 percent drop in performance 3 ½ hours after challenge with active capsules. The same group found later that FD&C Red no. 3 dye inhibited the uptake of all the neurotransmitters and their precursors tested.

In Food Additives and Hyperactive Children7 C. Keith Connors, a leading authority on hyperactive children states:

On the basis of all the evidence available at this time, in answer to the question, "Is there anything to Dr. Feingold’s hypothesis?" one might answer, "Yes, something – but not much and not consistently." As far as Dr. Feingold’s diet is concerned, the facts show repeatedly that parents and teachers rate the children as improved in behavior after the children are placed on the diet. Just as Feingold claimed, at least 50 percent show such improvement, but these changes appear to be due largely to placebo phenomena or other nonspecific factors. On the other hand, several studies on single cases and groups of children have shown that artificial colors produce interference with learning and performance. This latter finding may be dose-related and depend on the total amount ingested at one time, and possibly on the timing with respect to previous exposure to colors. No studies have demonstrated that this deleterious challenge affect of the artificial colors is in any way dependent on or related to the removal of the colors via Feingold’s diet. Most of the studies find that a small number of children who show improvement on Feingold’s diet also react adversely when given a challenge of the colors in a double-blind fashion. These findings suggest that a rather small number of children – perhaps less than 5 percent of those who are genuinely hyperactive – have some specific sensitivity to the artificial colors. The "dramatic" nature of the effects has been grossly overstated by Dr. Feingold, except insofar as placebo effects are dramatic among people who are at their wits ends with difficult and unmanageable children. . . . We have tried to show evidence in this book that patient and serious attempts to find evidence in favor of Feingold’s hypothesis have been carried out in many laboratories; that no clear-cut and consistent evidence has emerged in favor of the hypothesis.

Connors does recommend that the hyperactive child be given a "proper diet," under the supervision of a pediatrician or other trained nutritionist and with a broad examination covering the medical developmental history, school information, and environmental factors. "It does no harm," he believes, "to provide a diet with the minimum of artificial ingredients, as long as sound nutritional principals are followed." He also recommends the avoidance of carbon monoxide, radiation, pesticides, cigarette smoke, and lead fumes from cars, as well as the use of proven therapies.

. . . the hyperactive child [should] be given a "proper diet," under the supervision of a pediatrician or other trained nutritionist and with a broad examination covering the medical developmental history, school information, and environmental factors.

In a recent article,8 Zametkin and Rappaport review the history of Attention Deficit Disorder with Hyperactivity (ADDH) and biochemical studies including hypotheses involving some neurotransmitters (the catecholamines norepinephrine and dopamine). In summary they say:

Catecholamine function and its modulation are very probably involved at some level in the pathogenesis and treatment of Attention Deficit Disorder with Hyperactivity. All efficacious drugs have clearcut and dramatic effects (at least in vitro and demonstrated commonly in vivo) on catecholamine metabolism . . . . A role for norepinephrine metabolism in the pathophysiology and treatment of this disorder is highly likely given the extensive laminar and tangential and regional distribution of noradrenergic innervation of cortex and the effect of norepinephrine on the biosynthesis of dopamine . . . . Such a model might account for the wide variety of clinical agents effective in treating symptoms of ADDH. Different sites of dysfunction in this "circuit" would account for the array of presenting symptomatology from the pure attentional to the more impulsive.

So we see that artificial dyes and flavors have some influence on certain neurotransmitters although the mechanisms have not yet been worked out. There is more and more evidence that Dr. Feingold was onto something.

In my own practice, in about 50 percent of the children with ADDH a heavy intake of artificial dyes, flavors, or salicylates has been a major contributor. Other possible factors include food and other allergies, food intolerance, chemical sensitivities, . . .

In my own practice, in about 50 percent of the children with ADDH a heavy intake of artificial dyes, flavors, or salicylates has been a major contributor. Other possible factors include food and other allergies, food intolerance, chemical sensitivities, heavy metal burdens, vitamin and mineral imbalances, prostaglandin abnormalities, amino acid excesses and deficiencies, and fluorescent lights. On the psychological side, family stress, developmental delays, anxiety, depression, boredom in school, and learning disabilities can contribute to ADDH and behavioral problems. In the more traditional medical area, hyperthyroidism, enuresis, seizures (especially partial complex or absence types), sleep apnea, pinworms, and chronic otitis media are also possible factors. Some drugs, e.g. phenobarbital and some of the phenothiazines, can cause hyperactivity. Many of the above possibilities need to be evaluated by a competent professional.

At home, much can be done. The family environment is crucial, and this environment includes children’s (and adult’s) nutrition. We can all, with some knowledge and effort, do a great deal to enhance our overall health by eating cleaner foods – those unadulterated from the beginning of their growth to the point they are consumed. To be totally clean would be ideal, though it is a goal not easily achieved. To improve the situation, however, is within the reach of us all.

[I ask the family cook] . . . to buy fresh foods as the preferred foods, assiduously avoiding sugar, often the carrier of artificial colors and flavors, and all other foods with artificial colors and flavors. Common offenders are hot dogs, lunch meats, pop, "milk" shakes, fast food snacks, candy, cookies, most ice creams, . . .

I begin by asking the family cook, usually the mother, to buy fresh foods as the preferred foods, assiduously avoiding sugar, often the carrier of artificial colors and flavors, and all other foods with artificial colors and flavors. Common offenders are hot dogs, lunch meats, pop, "milk" shakes, fast food snacks, candy, cookies, most ice creams, dyed cheeses, and some frozen and canned foods. Many children are also salicylate-sensitive and need to avoid foods containing natural salicylates. Help with this is available from the Feingold Association9 and NOHA.10 There is an excellent format for a school food program, by Sara Sloan, which has proved to be very helpful to schools and day-care centers.

Some children need special attention and a special evaluation to focus on the causal factors. Possible tests include mineral analysis, vitamin and amino acid assays, thyroid function, EEG, allergy, chemical sensitivity, and glucose tolerance. Some professionals now pay attention to nutritional and ecological factors as well as the more traditional ones. These include physicians, nutritional consultants, and other health professionals. NOHA can help you find one. There is also much merit to pushing your own health-care provider to explore these newer treatment modalities.

Drugs such as Ritalin, Cylert, Tofranil, Atarx, and others have been used to quiet down children and some adults with ADDH and behavior disorders. In my opinion, they can be of help but should generally not be the first treatment used; often they can be avoided when the causes are found and treated.

We used to believe that children simply outgrew their hyperactivity by the time they reached their middle teens. Long-term follow-up studies and the experience of history have now taught us that some adults do not escape their old problem; their symptoms shift to more subtle forms that are largely undiagnosed and untreated.

Drugs such as Ritalin, . . . have been used to quiet down children and some adults with ADDH and behavior disorders. In my opinion, they . . . can be avoided when the causes are found and treated.

Though we don’t yet understand the underlying mechanisms of ADDH, there is some information and there are a number of hypotheses. Fortunately, we do have enough empirical data to take action, and we can expect to get some results. This at least we can do.

_______________________

1Feingold, B., Presentation at the American Medical Association meeting in New York City, June 1973.

2Harley, J.P., R.S. Ray, L. Tomasi, P. Eichman, P.G. Matthews, R. Chun, C.S. Cleeland, and E. Traisman, "Hyperkinesis and food additives: Testing the Feingold hypothesis," Pediatrics, 61:818-28, 1978.

3Williams, J.I.,D.M. Cram, F.T. Tausig, and E. Webster, "Relative effects of drugs and diet on hyperactive behaviors: An experimental study," Pediatrics, 61:811-17, 1978.

4Weiss, B.,S. Margen, J.H. Williams, B. Abrams, B. Cann, L.J. Citron, J. McKibben, D. Ogar, and S. Schultz, Final report on phase 2 FDA Contract No. 223-76-2040, December 1978.

5Swanson, J.M., and M. Kinsbourne, "Artificial food colors impair the learning of hyperactive children," Report to the Nutrition Foundation, 482 Fifth Avenue, New York, NY, 1979.

6Sobotka, T.J., "Estimates of average, 90th percentile and maximum daily intake of FD&C artificial food colors in one day’s diet among two age groups of children," Food and Drug Administration memorandum, July 1976.

7Conners, C.K., Food Additives and Hyperactive Children, New York: Plenum Press, pp.107, 110, 1980

8Zametkin, A.J., and J.L. Rappaport, "Neurobiology of Attention Deficit Disorder with Hyperactivity: Where have we come in 50 years?" J. Acad. Child & Adol. Psychiat., 26:676-86, 1987.

9Feingold Path of Illinois, P.O. Box 3507, Glen Ellyn, IL 60138-3507.

10NOHA, P.O. Box 380, Winnetka, IL 60093.

Article from NOHA NEWS, Vol. XIII, No. 1, Winter 1988, pages 2,5-6.