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Developmental Disorders and Food Additives

By Margaret Lahey and Shari Rosen
BAMFORD-LAHEY CHILDREN'S FOUNDATION

DEVELOPMENTAL DISORDERS AND FOOD ADDITIVES

Processed foods usually contain additives of some sort. The hypothesis that some of these additives can cause behavior and attention problems is discussed here.

INTRODUCTION

Food additives include food coloring as well as flavor enhancers such as MSG, preservatives such as BHA and BHT. Salicylates are also occasionally added to food. A wide range of adverse reactions is associated with food additives in approximately .03 to .23% of people and diagnosis is usually based on placebo-controlled oral provocation tests (Madsen, 1994; Wuthrich, 1993). Prevalence of food additive intolerance in children is estimated at 1 to 2% and is apt to be found in atopic children where the additive aggravates an existing hypersensitivity to some other substances (Fuglsang, Madsen, Savel, & Osterballe, 1993; Madsen, 1994).

A common additive that has been associated with adverse reactions is food coloring. The FDA is in charge of approving new colors and certifying whether or not a particular coloring can be used in food. Lists of colorings can be found on the FDA website. Color additives certified for use in foods include: blue #1, blue #2, green #3, red #40, red#3, and yellow#4 and yellow#5 plus two others restricted to specific uses (orange B and cirrus red#2). Other colors exempt from certification include beta-carotene, beet powder, canthaxanthin, caramel color, carrot oil, grape color extract, grape skin extract, paprika, tumeric, and vegetable juice. The certified color yellow #5, or tartrazine, is used in beverages, ice cream, preserves, cereals, and custards, has been associated with reactions (usually hives) in some individuals

Moreover, some people are sensitive to salicylates whether found in foods or medications. Salicylates are found naturally in many fruits and vegetables and are added to some food products. Foods naturally high in salicylates include berries, grapes, oranges, dried fruit, olives, tomatoes, tea, some herbs and spices, as well as some licorice, peppermint, and honey products (Swain, Dutton, & Truswell, 1985). Salicylates have an analgesic effect and have been used for centuries to relieve pain. Salicylic acid is derived from willow bark and is used in many medications. Aspirin is a salicylate and many drugs use salicylatic acid (e.g., Alka Seltzer). Some people are sensitive to salicylates and can only handle small quantities. This sensitivity can be manifested in many ways including headaches, lack of concentration, cognitive and perceptual disorders, breathing problems, and hyperactivity. Toxicity from salicylate can result in acid based problems, which often progresses from respiratory alkalosis to metabolic acidosis, electrolyte abnormalities, gastrointestinal problems, prolonged bleeding time, and can effect the central nervous system resulting in confusion or even coma. Dose related changes in motor activity that varied with sex, strain, and bedding conditions have been reported in rats at levels less than those causing overt toxicity (Buelke-Sam, Kimmel, Nelson, & Sullivan, 1984).

DEVELOPMENTAL DISORDERS

Probably the leading proponent of the hypothesis that food additives can cause hyperactivity in children was Dr. Benjamin Feingold, an allergy specialist. Feingold (1975) reported that dyes, preservatives, and salicylates could cause hyperactivity in children and his proposed diet for children with hyperactivity eliminated all artificial colorings, flavorings, and sweeteners as well as all foods that were naturally high in salicylates or that contained salicylates. This sparked international inquiry with mixed results. Most of this research has focused on children with symptoms similar to what is currently referred to as ADHD.

A number of reviews of these data have been published (e.g., Atkins, 1986; Breakey, 1997; Jacobson & Schardt, 1999; Kavale & Forness, 1983; Kidd, 2000; Wender, 1986). Many of the reviews discuss the problems with the research designs that make data difficult to interpret. For example, symptom change was often subjectively estimated, early reports were often anecdotal without controls, and even in studies that were double-blind placebo-controlled challenges, the placebos were often inappropriate (e.g., Atkins, 1986). In a meta-analysis of early research, Kavale and Forness (1983) concluded that diet restrictions such as those suggested by Feingold did not significantly affect behavior. However, their meta-analysis averaged reactions of all children so any effect on subgroups would have been lost (Jacobson & Schardt, 1999). Likewise, Wender (1986) concluded that there was little, if any, demonstrated effect of special diets on hyperactivity. According to Breakey (1997) later research tended to use primarily subjects where a reaction to food was suspected; and then eventually separated children who had other types of allergies. These later studies were better controlled (using a wider range of food challenges and children where sensitivity was suspected) and were more likely to find that dietary intervention yielded a significant change in behavior. Positive findings were most likely for younger children who had a family and/or personal history of allergy even though the offending substances and correlated symptoms varied among the children (Breakey, 1997).

An excellent and more recent summary and critique of studies on diet and behavior can be found in a report written for the Center for Science in the Public Interest by Jacobson and Schardt (1999); the report is entitled Diet, ADHD and Behavior and is available on the web. The authors summarize and review 23 double-blind studies in which the behavior of subjects was examined when they consumed suspect substances as well as when they consumed placebos. However, some of the studies used substances in placebos that could also have triggered allergic reactions (e.g., chocolate, wheat). Despite this 17 of these studies found evidence that the behavior of some (ranging from 9-100%) children are negatively affected following consumption of artificial colors or particular foods (e.g., Carter, Urbanowicz, Hemsley, et al., 1993; Goyette, Connors, Petti, et al., 1978; Kaplan, McNicol, Conte, et al., 1989; Pollock & Warner, 1990; Rowe & Rowe, 1994). Since their review was carried out, at least two more double-blind studies have supported this view (e.g., Reuters Medical News, 2001c; Schmidt, Mocks, Lay, et al., 1997). In addition, a number of non-double-blind studies that compared the behavior of children when they were on a restricted diet with behavior when they were not on such a diet found that diet affected behavior in some children (e.g., Boris & Mandel, 1994; Carter, et al., 1993). The effect of food on behavior of a subgroup of children with ADHD was supported by topographic mapping of brain electrical activity in children considered to have food-induced ADHD (Uhlig, Merkenschlager, Brandmaiser, & Egger, 1997). These researchers examined EEG recordings of children while they were on a restricted diet as well as when they were fed offending foods. They found an increase in beta1 activity in the frontal-temporal areas of the brain following consumption of provoking food.

A few studies have examined the relation between ADHD and allergies in general. Some data indicate that children with ADHD are more likely to have allergies than the general population of children (e.g., Rapp, 1991; Roth, Beyreiss, Schlenzka, & Beyer, 1991), whereas other data question such a relationship (e.g., McGee, Stanton, & Sears, 1993). Food sensitivities have been found more often in children who have other allergies (e.g., Rowe & Rowe, 1994) and in particular with children who had atopic skin symptoms (Fuglsang, Madsen, Halken et al., 1994). Interestingly, atopic dermatitis has also been associated with a diagnosis of ADHD (Peck, 2003). One explanation for a possible connection between allergies and ADHD is that allergies cause cholinergic/adrenergic imbalances in the central nervous system that lead to poorly regulated arousal levels (e.g., Marshall, 1989). Others have found an association between food allergy and serous otitis media (Nsouli, T., Nisouli, S., Linde, et al., 1994); an association between otitis media and symptoms similar to ADHD has also been reported (e.g., Hagerman & Falkenstein, 1987; Hersher, 1978). Further research is needed to better understand the relationship between ADHD and autoimmune problems such as allergies.

A large number of people and many health organizations dismiss the idea that dietary factors, such as food additives and salicylates, can be a factor in ADHD. Indeed, it would appear that the behavior and attention problems of the majority of children with ADHD are not related to the ingestion of food additives or salicylates. However, review of the data suggests that there may be sub-groups of children with ADHD whose behavior problems are exacerbated, if not caused, by reactions to certain foods as noted in Hypothesis C2. Evidence suggests that such children are more likely to have allergies to other substances. We cannot dismiss the issue even though the percentage of children in the subgroup is small. Most would agree that if removing particular food substances improved behavior of even a few children it would be safer form of treatment for these children than the administration of drugs whose potential side effects in children are not yet fully understood. Clearly, further well-designed research into the role of reactions to food in ADHD is needed to better understand which children may have problems associated with reactions to food additives and salicylates or any aspect of diet.

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