Saturday, February 5, 2011

Food Elimination Diet and ADHD

There is little argument that diet has a contribution in the major diseases of civilization, such as heart disease and type II diabetes.  However, the effect of diet on mental health disorders remains controversial in the conventional circles.  I'm not entirely clear why, as it has been known for a decade or more that different kinds of inflammation mediate both metabolic syndrome and the depressive disorders and schizophrenia.  It seems logical to me to look for dietary or environmental insults that would predispose one to develop these disorders, and not just in fringe journals, or Australia.

But then, I also think it is logical that our immune systems are responsible for heart disease and high cholesterol, not that our livers (in a desperate effort to do us in) release cholesterol into the bloodstream to clog our arteries like an old sock dropped into the disposal.  The reason I find the immune system to be a logical culprit is that the whole purpose of the immune system is to KILL THINGS and wreak havoc.  Sometimes your general turns tables on you.  Way of the wild.  But I'm rambling.

ADHD in children.  Controversial, of course, as stimulants are a primary treatment.  The controversy looms large in part because behavior is primarily felt to be a parental/discipline problem.  And there has always been the idea that "sugar" makes kids "hyper" - so we have this cultural meme of lazy parents and spoiled kids chowing down on skittles and garbage, driving the teachers nuts - the teachers, being lazy themselves, want the kids medicated into oblivion so that no one will have to do any work (especially, presumably, the psychiatrist, who happily prescribes addictive drugs in a 4 minute visit to keep the families coming back and to collect a large paycheck.)  Do we really live in a world where everyone entrusted to keep our kids safe and happy is hopelessly lazy and corrupt?  Because if the cultural meme is true, we are screwed.

Let's get to reality, where families really suffer with the disorder, and teachers want kids to do better, and doctors try to spend some time in multifaceted ways to help.  ADHD is a recipe list of symptoms - hyperactivity and inattentiveness being primary.  Part of the issue is the stupid recipe list - ADHD symptoms are a function of problems with the frontal lobe of the brain, and while several neurotransmitters are involved, an inefficiency of dopamine transmission may be the key player.  And, indeed, there are some families with lots of ADHD who have known genetic issues with their dopamine receptors.   There.  Simple.  It's dopamine.  A kid has the symptoms, hand them dopamine in a ritalin tablet, and call it a day. 

Not so fast.  Problem is, a lot of different issues can cause problems with the frontal lobe and other associated ADHD areas, not just genetic issues.  Depression, for one, seems to torch our ability to stay focused.  So will anxiety.   Lack of sleep (I'll be more specific about sleep and ADHD symptoms and defiant behavior in another post).  Other kinds of inflammation.  Issues with a thinning frontal cortex in development.  The vulnerability to the different insults will be genetic, and families in general face similar environments, so a family with lousy sleep or lousy eating habits might all turn up with ADHD symptoms, just like the family with the primary dopamine problem.  Stimulants will generally help perk up the frontal lobe and behavioral changes can help too, regardless of the cause - but one never wants to ignore an ongoing environmental insult that is damaging the brain while you correct the symptoms with a band-aid.

The stakes are high.  Kids with ADHD are much much more likely to grow up and get divorced, lose jobs, be in car accidents, and commit felonies.   We don't want to dismiss the problem as non-existent and focus entirely on behavioral treatments, but we also don't want to throw ritalin at every kid who spazzes out in school.  It's a complex issue, a complex and multifaceted disorder, and for a while now I have suspected dietary causes to be the problem for some kids.  I've even blogged about it a couple times - mostly reviewing the work of a British group who did a well-designed study of 300 some-odd kids in 2007 called the Southampton Study.

In short, the researchers gave kids in the community (so just a random sample of kids, not particularly any diagnosed with ADHD, though some of them may have been diagnosed with it), in blinded crossover fashion, placebo drinks or two types of food additive drinks, with washout periods in between drink trials.  Kids on the additive-laden drink were significantly more hyper in the reviews of parents, teachers, and independent observers.  It's the kind of study that should really make your ears perk up - sure, it ought to be repeated, but the results were pretty definitive.  (When I talk about conventional medicine's lack of support for the idea that diet could possibly be related to mental illness, the title of an article in Harvard's Mental Health Letter in June 2009, two years after the Southampton Study, was " "Diet and Attention Deficit Hyperactivity Disorder - Can some food additives or nutrients affect symptoms? The jury is still out.").


Well, the British researchers continued to dig deeper into the results of the Southampton Study, and last year they published another study in The American Journal Of Psychiatry (these guys to great work, and get their stuff published in all the premier journals).  I blogged about it here - ADHD, Food Additives, and Histamine.  Again, in short, the researchers checked out the genetics of the same kids from the Southampton Study, and found that kids who were made more hyper by the food additives were significantly more likely to have certain problems with genes regulating their histamine system.  Anyone who has ever taken a benadryl for swollen eyes and a runny nose on a pollen-laden spring day will know what histamine is, more or less.  Our bodies release it in response to some sort of allergenic stimulus.  I made the point in my blog that the Southampton study seems to show us that, indeed, in some children (not all!), ADHD symptoms are a food allergy.

This week, another excellent study was published in The Lancet that took the next logical step of scientific exploration.  There is also an editorial.  (Neither are free full text, unfortunately.)  The INCA study is Belgian, and involved a randomized controlled trial with an open label phase (looks like it was single-blinded) followed by a double-blind crossover trial of an elimination diet vs. a "healthy diet" (control).  The 100 children studied were were 4-8 years old and did have a diagnosis of ADHD.

The results were pretty astonishing (well, maybe not to me, or to a lot of parents, but to the diet skeptics out there, it should be pretty darn astonishing).  Nearly two-thirds of the kids on the elimination diet for 9 weeks experienced significant reduction in ADHD symptoms and oppositional defiant behavior.  The symptoms returned when the kids went back to the "healthy" control diet.  The most up-to-date crowd of "Paleo" diet followers will grin when they hear the elimination diet - it was restricted to rice (some might avoid white rice for the excess carbohydrate with little other nutrient value, but most will agree it is essentially toxin-free and not objectionable "safe starch"), meat, vegetables, pears, and water.  There was a less strict diet where small amounts of potatoes, wheat, and other fruits were allowed but by the end of week 2 of the diet, 41% of the kids had no response to the less strict version and were placed on the stricter diet.

There were a couple of interesting wrinkles.  The kids were all tested for IgG antibodies to food, supposedly helping one sort out food intolerances.  These tests are widely used by doctors and para-professionals alike to diagnose food allergies, but when you get down to it, there is not a lot of evidence these tests tell you much about what you might actually be allergic to.  IgG antibodies simply mean that somewhere along the way your bloodstream was exposed to food allergens.  To be honest, I think people with tons of positive IgG food allergies have leaky guts, that wheat and poor gut biome are reasonably likely culprits, and the foods that show up in the IgG test are a random sampling of what happened to make it through the leaky gut.  In the INCA study, the kids were carefully rechallenged with their IgG + foods, and their symptoms of ADHD seemed to have nothing to do with the IgG test.  So I'm right ;-)  (maybe).

A quote from the Medscape article summarizing the findings and the editorial:

Dr. Pelsser's team concludes that a strictly supervised restricted elimination diet "is a valuable instrument to assess whether ADHD is induced by food, [but] the prescription of diets on the basis of IgG blood tests should be discouraged."

In her [editorial], Dr. Ghuman notes restricted elimination diet studies are "complex and challenging." The INCA study was "well-designed and carefully done, showed a benefit with a supervised elimination diet, and provides an additional treatment option for some young children with ADHD.  "For interested parents," Dr. Ghuman told Medscape Medical News, "clinicians should encourage them to seek the advice of the child's primary care provider and a nutritionist for appropriate monitoring of the child's nutritional status and needs. The parents will need appropriate guidance and supervision for a structured protocol to determine any benefit and identify incriminated foods."

So more evidence piles up.  In fact, the same researchers ran a pilot randomized controlled trial with 27 kids published in 2009 (free full text this time) and found that 11 of 15 children on the study diet improved by at least 40%, whereas none of the 12 kids on the control diet improved. 

I may not be completely off base with my basic premise after all.

(Thanks to Dr. Trevisan for alerting me to the Medscape article!)

13 comments:

  1. Too bad the less strict version of the diet included wheat!

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  2. Do we really live in a world where everyone entrusted to keep our kids safe and happy is hopelessly lazy and corrupt?

    Not sure why most people trust bureaucrats... It seems safer not to have kids, eh? ;-)

    Dr. Ann Childers talks about treating an ADHD child with diet in this interview with Jimmy Moore.

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  3. Beth - I believe the researchers were running with the idea or specific food intolerances (thus the use of the dubious IgG test) rather than the paleo idea of a total food toxin burden that some people tend to tolerate better than others. It looks like 1/3 of the kids who eventually responded did so after wheat, potatoes, and the other fruits were removed.

    Js290 - not used to thinking of parents, teachers, and doctors as bureaucrats. But one ought to protect ones kids from the USDA ;-)

    I haven't listened to that podcast but it is on my list - Dr. Childers is the only other whole foods/nutrition psychiatrist I know of - she's in Oregon so we have the northern coasts covered, anyway.

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  4. Oh, I like that sentence from the study:
    After the baseline period, the control group followed the first phase until week 13 and received healthy food advice according to the guidelines of the Dutch Nutrition Centre.

    They use "healthy food" throughout the study and always keep a straight face. Either they really still believe it (hook, line, sinker and all) or they don't want to loose their jobs...

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  5. Sorry Beth - not 1/3, far less than 1/3. Can't do math today for some reason.

    Tony - straight face indeed! But they are actually looking for specific food intolerances, when perhaps they should be looking at an overall dietary inflammatory load. Silly, huh?

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  6. Amazing timing. My ex-husband just sent me a link to the interview Pelsser did for Dutch TV last night. It's in Dutch, unfortunately, so I won't bother posting it, but the full paper is available here in English, for anyone that's interested. http://www.adhdenvoeding.nl/cms/wp-content/uploads/2011/02/Pelsser-The-Lancet-2011-Publication-INCA-study.pdf

    I have ADHD as well as being incredibly intolerant of a number of food items, gluten being a big one. As an adult with ADHD I can absolutely attest to the fact that diet (mostly paleo) can have a huge influence on symptoms. Unfortunately it doesn't completely eliminate them for me so I do take meds as well. I wasn't diagnosed until I was 41, perhaps a lifetime of ‘poisoning’ myself has taken its toll. I would also be interested to see a breakdown of the types of ADHD and their response to diet. I’m predominantly inattentive, which some actually consider a distinct disorder in itself. I’m also looking into genetic testing to see how that all ties in. Fascinating stuff.

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    1. Have you ever looked into any herbal tinctures? In my instance I have struggled with depression, anxiety, oppositional-defiance disorder, and ADHD. All of which have been diagnosed by a psychiatrist when I was around the ages of 8-16, I am 20 years old now. I currently take a multi compound extract that contains St. Johns Wort(Hypericum perforatum), Kava(Piper methysticum), Skullcap(Scutellaria lateriflora), and Prickly Ash(Zanthoxylum clava herculis). I also take an extract of Bacopa monnieri, as well as Passion Flower(Passiflora incarnata). The Passion Flower is the most recent addition but after 18 days I have already begun to feel quite a difference in my overall mood and sense of motivation. My recent change in diet to mainly meat and little vegetables to supplement could very well have an effect of my improvement as well.

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  7. I have a son who is ADHD and oppositional. He is currently taking two different medications to help his symptoms. Even with the medication, his symptoms are very strong. I don't think that a mere 40% improvement at best would make his symptoms livable for him. Personally, I like my house too much to risk taking him off meds to feed him rice and chicken. Since he has been on his medication we have not had one kicked in door or hole in the wall. Before medication, he broke nearly every door and kicked 6 holes in the wall within a one year period. ADHD/ODD is not this fluffy thing that people talk about. It is not just kids who cannot sit still. It is an inability to self-regulate, and I think studies like these really do diminish the seriousness of the condition.

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  8. Patti - while I understand your concern with taking your child off of prescription medication, it is also important to understand the long-term impact of drugs such as dexedrine and stratera. I work as a special education teacher who currently has 6 students with severe ODD and ADHD on my caseload, needless to say I am extremely busy and completely understand the magnitude of these disorders. If I may be so bold, my suggestion would be to try the elimination diet and see what happens, what do you have to lose? 1 month off of medication may be difficult, but may also lead to long-term benefits for your child and a substantially reduced med load (possibly completely wiped out)which will have lasting benefits to your childs physical and emotional well-being. The 1 month may be awful, you may see no improvements, but there is a pay off it will far outweigh the difficult month!

    Goodluck and all the best to you and your child!

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  9. My daughter very likely has ADHD (waiting on diagnosis), and she absolutely has Encopresis (shhhh, nobody talks about this one!). By the recommendation of her Gastro Intestinal Doctor we were asked to remove all dairy from her diet in correlation with the Encopresis (she has also been tested for Celiac disease - no results yet). Casein, a milk protein, has been linked to exasperating some of the conditions of children that fall within some of the 4-A Disorders (Autism, ADHD, Asthma, Allergies)

    http://www.rhinebeckhealth.com/rhc/4-a%20disorders.php

    Anyways, I'm struggling with maybe getting the IgG tests done to confirm the allergy - but am not finding enough data telling me that it actually works, nor that a result from their labs offers any other result than a casein and gluten "intolerance" - seems to be a running theme in their results back....

    I'm hoping a regular old allergy test (IgE) will confirm her Casein allergy before I attempt IgG - because after an elimination diet done recently I am sure that she does have a casein allergy. With that said...I feel like I need "proof" to determine that the allergy exist - and I guess I determine proof by medical evidence. :P

    Perhaps something I have to get over.

    If my daughter has ADHD then she is pretty high functioning I would say - at least in social situations and probably a bit better since the casein diet was introduced - though more observation is required.

    She has lots of friends and is pretty "well behaved" at school less the hyper activeness, hyper-sensitivity, hard time concentrating on subjects she finds difficult, and hyper focus for subjects she does like - at home the challenge becomes more evident as she has severe and often violent outburst, extreme sensitivity emotionally and to sensory stimuli (no whispering in ears - no way), extreme need to have things organized just so and not to have any of her possessions touched.
    Anyway - apparently casein (and gluten) are often associated with causing a child with ADHD to have even less control over their actions.

    So...after much reading about how the frontal lobe of most children with ADHD is smaller and how removal of two peptides (G and C) can help ADHD affected children because in most children with ADHD these peptides can be confused as opiates by the brain, I am convinced of two things:

    ADHD is not 'curable", but it can be managed. And diet is absolutely a way to help. I'm surprised Patti P shut it down immediately. Why take him off his meds? Just add the Gluten free/Casein free diet to your normal lifestyle and see if it helps. If it does, maybe put the boy on a smaller dosage of meds...or maybe not. I don't think we can ever judge people who choose to use meds. All we can do is offer information and choice.

    I hope to read more about all this soon - great blog.

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  10. The strict diet is also low salicylate, and the less strict added in more fruits, likely high salicylate fruits. ADHD kids are often very salicylate sensitive (see Feingold Diet).

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  11. does this mean that fish isn't ok?
    As well why pears are ok and not other fruits?

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  12. Emily,
    Really appreciated this piece, thanks for pulling it together. We're on the same path! I've bee writing about these issues for some time over at CorePsych Blog, a recent example here:http://www.corepsychblog.com/2012/09/adhd-insights-brain-body-immunity/

    Hope we can meet one day!
    Chuck
    Author: New ADHD Medication Rules

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