ADHD Diet Plan Gets Mixed Reviews

[Guest guest]

A limited diet that focuses on a few selected foods including rice, meat,

and vegetables may provide symptom relief for children with attention

deficit/hyperactivity disorder, researchers said, but skeptics question the

validity of their study.

After five weeks, 64% of those on a restricted diet had significant

improvement in symptoms; no improvement was seen in those who were not on

the restricted diet, Lidy Pelsser, MD, of the ADHD Research Center in

Eindhoven, the Netherlands, and colleagues reported in *The Lancet*.

" We think that dietary intervention should be considered in all children

with ADHD, provided parents are willing to follow a diagnostic restricted

elimination diet for a five-week period, and provided expert supervision is

available, " they wrote.

In a comment to ABC News and *MedPage Today, * Rosenberg, MD, a child

psychiatrist at Wayne State University, said that the finding " is not

unexpected and lends additional evidence that diet and other environmental

factors may be important in ADHD. "

He said he would be willing to try a restricted elimination diet, " and in

some ways we already do this for certain patients and with their parents,

although not necessarily the systematic approach studied here. "

Others contacted by ABC News and *MedPage Today*, however, were skeptical of

the findings.

Harvey Leo, an allergist and immunologist at the University of Michigan,

said in an e-mail, " There are severe limitations to this study, and after

reviewing the current paper, I do not think any of the data presented [have]

any true validity. "

He noted the lack of strict monitoring of compliance with the dietary

recommendations and the lack of information on the exact makeup of the diet.

He said the benefits observed were likely due to enrollment in the study and

rigorous monitoring -- rather than an effect from diet modification --

because children with ADHD respond to structure and organization.

" If the parent was truly committed to the diet, " Leo said, " I think the

child would see some benefit in behavior. "

Daines, MD, a pediatric allergist and immunologist at the University

of Arizona, called the study " interesting, but flawed, " pointing to the lack

of blinding in the study groups, which would potentially affect all of the

data.

Also wary of the findings was Pelham, PhD, a psychologist at the

University of Buffalo, who cited studies conducted over the past 30 years

that have failed to support a consistent relationship between dietary

manipulations and ADHD symptoms.

" One open study allegedly demonstrating a relationship does not change my

mind, " he wrote in an e-mail.

Foods can cause physical reactions, such as eczema and asthma, that affect

other organs, so it's been suggested that what patients eat may also affect

the brain. Thus, diets built around hypoallergenic foods are believed by

some to be effective for ADHD.

Pelsser and colleagues conducted the Impact of Nutrition on Children with

ADHD (INCA) Study, a randomized controlled trial that enrolled children ages

4 to 8 from the Netherlands and Belgium who'd been diagnosed with the

disease.

The children were assigned to either five weeks of a restricted diet, or

were given written instructions about a healthy diet and placed on a waiting

list. The researchers used the few-foods diet, which includes rice, meat,

vegetables, pears, and water, and can be complemented with specific foods

such as potatoes, fruits, and wheat.

After the initial five weeks, those in the restricted-diet group who had

improved ADHD symptoms entered a four-week, double-blind, crossover food

challenge phase, in which they ate high-IgG or low-IgG foods to assess

specific reactions.

A total of 100 children were enrolled; most were boys and the mean age was

6.9.

The researchers found that at the end of the first, five-week diet phase,

symptoms of ADHD and oppositional defiant disorder significantly improved in

64% of children in the diet group; there was no improvement among controls.

The mean difference in ADHD Rating Scale (ARS) score after five weeks was

significantly lower in the diet group than in the control group for both

masked pediatrician and unmasked teacher ratings (*P*<0.0001).

Scores on the abbreviated Conners' scale (ACS) -- which assesses

hyperactivity, impulsivity, attention, mood, and temper tantrums -- were

also significantly lower in the diet group for parent and teacher ratings (*

P*<0.0001).

The researchers saw no increase in IgE levels associated with clinical

response, which suggests that the underlying mechanism of food sensitivity

in ADHD is nonallergenic.

In the second phase of the study, the 30 children who responded to the

restricted diet proceeded to the challenge phase, which involved two weeks

of three high-IgG and three low-IgG foods added to their regimen.

The researchers saw that 19 of these children (63%) had a relapse in ADHD

symptoms after one or both challenges.

In his comments, Daines said that the fact that one-third did not regress

makes " the interpretation [of the study findings] even more suspect. "

The IgG levels produced in response to certain foods didn't predict which

ones might lead to a negative effect on behavior, as an equal number of low

and high IgG challenges resulted in relapse, the researchers said.

" These results suggest that use of IgG blood tests to identify which foods

are triggering ADHD is not advisable, " they wrote, noting that in

complementary care, the tests are offered even though there is no evidence

for their efficacy.

Added Rosenberg, " It is not surprising that IgG blood tests did not predict

relapse of ADHD symptoms as this is a multifactorial, extremely

heterogeneous illness. However, it is an important lead and suggests that

diet, immunologic, and other factors are clearly involved in ADHD. "

The researchers acknowledged that the study may have been limited because

the parents, teachers, and researchers couldn't be blinded to the diets.

Still, they concluded that restricted diets may be considered in children

with ADHD, and that those " who react favorably to this diet should be

diagnosed with food-induced ADHD and should enter a challenge procedure to

define which foods each child reacts to, and to increase the feasibility and

to minimize the burden of the diet. "

In an accompanying comment, Jaswinder Kaur Ghuman, MD, of the University of

Arizona in Tucson, wrote that the study was " well-designed and carefully

done, showed benefit with a supervised elimination diet, and provides an

additional treatment option for some young children with ADHD. "

But Ghuman noted that 36% of the children either didn't respond to the diet

or were noncompliant, so it would be " helpful to know which children can be

predicted to respond to the diet. "

He also cautioned that a " stringent elimination diet should not continue for

more than five weeks without obvious benefit because of the time, effort,

and resources required to implement the restricted diet and because

long-term effects of dietary elimination on the child's nutritional status

are not known. "

Ghuman called for more research on the specific foods responsible for

hypersensitivity reaction.

*Primary source: *The Lancet

Source reference:

Pelsser LM, et al " Effects of a restricted elimination diet on the behaviour

of children with attention-deficit hyperactivity disorder (INCA study): a

randomised controlled trial " *Lancet* 2011; 377:

494-503.<http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%296\

2227-1/fulltext>

*Additional source:* The Lancet

Source reference:

Ghuman JK " Restricted elimination diet for ADHD: the INCA study " *Lancet *2011;

377:

446-448.<http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%296\

0133-5/fulltext>

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