Developmental Disorders and Sugar

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

DEVELOPMENTAL DISORDERS AND SUGAR

Intake of sugar has been hypothesized as a trigger for hyperactivity. In this section we examine the evidence about such a relationship.

INTRODUCTION

Dietary intake of sugar (including corn syrup, high-fructose corn syrup, honey) is high in the United States and has been increasing in the past decades with a 30% increase between 1983 and 1999 (CSPI, 2000). Much of this intake is related to sugar added to soft drinks, fruit drinks, baked goods, candy, and cereals. One of the major health concerns related to the ingestion of large amounts of sugar is its relation to the increase in obesity in the past two decades (CSPI, 2000; Ogden, Flegal, Carroll, & Johnson, 2002). Directly relevant to this paper is the claim for many decades (e.g., Shannon, 1922 as cited by Wolraich, Wilson & White, 1995) that sugar also affects behavior. Considerable anecdotal evidence still exists about the relationship between sugar and hyperactivity. Parents frequently report that their child is more hyperactive after high sugar intake and some correlational studies supported this (see Wolraich, et al. 1995). Moreover, a sharp drop in sugar level (i.e., hypoglycemia) following a surge in insulin from either direct consumption of sugar or from the conversion of carbohydrates to sugar in the body has been associated with behavior and attention problems (e.g., McAulay, Deary, Ferguson, & Frier, 2001).

DEVELOPMENTAL DISORDERS

Some evidence suggests that the metabolism of cerebral glucose of individuals with hyperactivity is reduced relative to controls (e.g., Ernst, Liebenauer, King, et al., 1994; Ernst, Zametkin, Phillips, & Cohen, 1998; Zametkin, Nordahl, Gross, et al., 1990) although other evidence does not support problems with glucose metabolism (e.g., Ernst, Cohen, Liebenauer, et al., 1997). In an examination of metabolic, hormonal and cognitive responses to oral glucose in children with ADHD and controls, Girardi and colleagues found no important differences in responses to glucose load and no effect on cognitive tasks that was related to glucose level (Giardi, Shaywitz, Marchione, et al., 1995). However, they found differences between groups in epinephrine and norepinephrine levels suggesting differences in catecholamine response.

Despite some mixed results on metabolism of glucose by those with ADHD and parental reports of improvement in children's behavior when they are fed a diet low in refined carbohydrates (thus reducing glucose in the body), little research evidence supports changes in behavior or learning related to ingestion of sugar or sugar substitutes. One study reported no change in aggressive behaviors but did find an increase in inattention on a continuous performance task for children with ADHD after ingestion of sugar but not saccharin or aspartame (Wender & Solanto, 1991). In another study, school lunch and breakfast diet in over 800 public schools was changed so that it was low in sucrose as well as two synthetic food colors (Schoenthaler, Doraz, & Wakefield, 1986). Following this dietary change for one year, mean scores on academic tests rose 8% over the rest of the nation's schools; it is not clear how much of the effect was sugar related. Further elimination of all artificial colors and flavors as well as BHT and BHA raised that gain to over 15% and gain in each school's performance ranking was positively correlated with the percent of children at that school who ate school lunches and breakfasts. This suggests that food additives may have accounted for more of the change than sugar. Most of the studies that examined behavior and measures of cognition in children following high intake of sugar and sugar substitutes (e.g., aspartame, saccharin) have yielded negative results (e.g., Bachorowski, Newman, Nichols, et al., 1990; Gross, 1984; Kanarek, 1994; Savaris, Schachar, & Zlotkin, 1990; Shaywitz, Sullivan, Anderson, et al., 1994; Wolraich, Lindgren, Stumbo, et al., 1994; Wolraich, Milich, Stumbo, & Schultz, 1985). The conclusion that sugar is not a major factor influencing behavior of children is supported in reviews of the literature of double-blind placebo-controlled studies of sugar challenges (e.g., Jacobson & Schardt, 1999; Krummel, Seligson, & Guthrie, 1996) and in a meta-analysis of sixteen studies (Wolraich, et al, 1995). It has been suggested that expectancy may have an effect on the ability of glucose to affect cognitive performance (Green, Taylor, Elliman, & Rhodes, 2001). There is, in fact, some evidence suggesting that glucose improves memory in healthy adults (e.g., Sunram-Lea, Foster, Durlach, & Perez, 2001, 2002a, 2002b).

The studies done to test the effect of sugar on behavior have been criticized for allowing high levels of sugar in the diet of the control groups, not eliminating possible dietary allergens in both control and experimental groups, and allowing both groups to drink soda during experiments (Kidd, 2000). Further research would appear needed to control for these factors before the role of sugar in exacerbating hyperactivity can be completely dismissed. Most would agree with the conclusion of Jacobson and Schardt (1999) that whether or not consumption of sugar does influence behavior, children and adults should consume less sugar than the average consumed in this country for nutritional reasons (and we might add for weight control). Foods with sugar often also contain other additives that could affect behavior such as food coloring, artificial flavors, and preservatives. Moreover, there is the possibility that diets high in sugar, or high in carbohydrates that convert to sugar within the body, can lead to or exacerbate intestinal problems such as yeast infections and intestinal permeability (e.g., Nieuwenhuizen, Pieters, Knippels, et al., 2003; Pescatore, 2003]. As discussed below, intestinal problems including intestinal permeability have been associated with some developmental disorders (Pfeiffer, 1996).

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