Feingold diet

The Feingold diet is a food elimination program developed by Ben F. Feingold, MD to treat hyperactivity. It eliminates a number of artificial colors and artificial flavors, aspartame, three petroleum-based preservatives, and (at least initially) certain salicylates. There has been much debate about the efficacy of this program. Some mainstream medical practitioners deny that it is of any value, while other medical practitioners, as well as many people living with ADHD and parents of children with ADHD, claim that it is effective in the management of ADHD as well as a number of other behavioral, physical and neurological conditions including salicylate sensitivity. The debate has continued for more than 30 years, involving not only consumers and physicians, but scientists, politicians, and the pharmaceutical and food industries.

The Feingold Program

The Feingold Program eliminates three groups of synthetic food additives and one class of synthetic sweeteners:

*Synthetic colors (FD&C and D&C colors)
*Synthetic flavors (several thousand different chemicals)
*Synthetic preservatives (BHA, BHT, and TBHQ)
*Artificial sweeteners (Aspartame, Neotame, and Alitame)

The above-listed colorings and preservatives are made from petroleum. cite web
url= http://www.fda.gov/bbs/topics/CONSUMER/CON00063.html
title= U.S. Food & Drug Administration, Red No. 3 and Other Colorful Controversies
accessdate= 2008-03-15
author= Dale Blumenthal
quote= Approved color additives were divided into two groups: those requiring FDA'scertification (synthetic dyes made mostly from coal tar and petroleumderivatives) and those exempt from FDA's certification (substances derivedfrom vegetable, animal or mineral products).] cite web
url= http://www.imadrugpat.org/foodadditives.htm
title= Food Additives
accessdate= 2008-03-15
quote= E319 Tert-ButylHydroQuinone (TBHQ) Petroleum based... E320 Butylated hydroxy-anisole (BHA) Petroleum derivative ... E321 Butylated hydroxy-toluene (BHT) Petroleum derivate.] The word "synthetic" is used instead of "artificial" because not all artificial colorings are eliminated by the program. For example, titanium dioxide and coloring made from iron oxides are acceptable, posing no problem for most people. Only FD&C and D&C colorings are eliminated. There are thousands of synthetic flavorings, from a variety of sources, most of which are not specified in ingredient lists. Due to the "de minimis" principle,cite web
url = http://www.feingold.org/Research/dye.html#Kroes2002
title=Threshold of toxicological concern (TTC) in food safety assessment.] safety and neurotoxicity studies are not required for these chemicals. Aspartame and its related chemicals have recently been eliminated from the Feingold Program because of evidence that they may be harmful to the nervous system.cite journal
author = Lau, K. and McLean, W.G. and Williams, D.P. and Howard, C.V.
year = 2006
month = March
title = Synergistic interactions between commonly used food additives in a developmental neurotoxicity test
journal = Toxocological Sciences
volume = 90
issue = 1
pages = 178–187
pmid = 16352620
doi = 10.1093/toxsci/kfj073]

During the initial weeks of the Program, certain foods containing salicylates are removed and may later be reintroduced and tested for tolerance, one at a time. Most of the problematic salicylate-rich foods are commontemperate-zone fruits, as well as a few vegetables, spices, and one tree nut. During this early period, foods like pears, cashews and bananas are used instead of foods like apples, almonds and
grapes.

Contrary to popular misconception, soft drinks, chocolate and sugar have never been eliminated on the Feingold Program, although moderation is encouraged when consuming such items. Families can often continue to eat the types of food to which they are accustomed, including desserts. It is a matter of picking brands free of the unwanted additives. Most of the acceptable foods are easily available at supermarkets.

History

Dr. Feingold was a pediatrician and allergist, and was considered a pioneer in the fields of allergy and immunology. [cite book
author=Allan Magaziner, Linda Bonvie, Anthony Zolezzi
title=Chemical-Free Kids: How to Safeguard Your Child's Diet and Environment (pp.62)
publisher=Kensington Books
year=2003 | id=ISBN 0758203691] He served as Chief of Pediatrics, Cedars of Lebanon Hospital, Los Angeles, CA; later he established a number of allergy centers for Kaiser Permanente of Northern California, and served as Chief of Allergy at the Kaiser Permanente Medical Center in San Francisco.

First recorded case

Since the 1940s, researchers world-wide had discussed cross-reactions of aspirin (a common salicylate) and Tartrazine (FD&C Yellow #5).cite web
title=National Health Museum
url=http://www.accessexcellence.org/HHQ/qow/qow05/qow051031.html
accessdate=2008-03-31] Dr. Stephen Lockey [cite journal
author = Lockey, SD
title = Allergic reactions due to F D and C Yellow No. 5, tartrazine, an aniline dye used as a coloring and identifying agent in various steroids
url=http://www.feingold.org/Research/lockey1959.html
journal = Annals of Allergy
volume = 17
pages = 719–21
date= 1959 Sept-Oct ] at the Mayo Clinic and later Dr. Feingold at Kaiser, found that eliminating both salicylates and synthetic food additives from patients' diets eliminated not only allergic-type reactions, but also behavioral changes in some of their patients.

The first clear case for Dr. Feingold was an adult patient referred to him for treatment of her severe hives in 1965. [cite book | author=Feingold, B.F.
title=Why Your Child is Hyperactive (pp.1-2)| publisher=Random House
year=1985 | id=ISBN 0-394-73426-2] Typical treatments had not worked for her. Dr. Feingold placed her on a low-salicylate diet with no synthetic coloring or flavoring. Soon her hives were gone, and the patient was happy.

Ten days later, however, her psychiatrist called Dr. Feingold to ask, "What did you do to my patient?" She had been receiving treatment for a personality disorder for years, but in less than two weeks on the diet, her behavior had noticeably improved. Both doctors were puzzled. Dr. Feingold asked his staff to watch for other patients who did not respond to standard treatments. He suggested the diet regimen to them, and sometimes it worked. As more reports of behavioral improvement came in, he began to use the diet for people - especially children - with behavioral problems as well as allergy, and eventually found the diet often worked for children with behavioral problems even without allergy symptoms.

He named the diet the K-P Diet for Kaiser-Permanente (and he liked the pun of "K-P" as Kitchen Police). [cite book | author=Feingold, B.F.
title=Why Your Child is Hyperactive (p.37)
publisher=Random House
year=1985 | id=ISBN 0-394-73426-2] Later, as this diet became more well-known for helping hyperactive and learning disabled children, the media dubbed it the "Feingold diet."

Early use of the K-P / Feingold diet

In his early work with children (and adults) who suffered from what was then called "minimal brain dysfunction" (MBD), Hyperkinesis, or Hyperkinesis-Learning Disability (H-LD), Dr. Feingold found that response was variable, depending on the age of the child and the presence or absence of a history suggestive of neurological damage. In 1976, he reported that in five separate programs, totalling 360 children managed with the K-P diet, 30% to 50% of them showed favorable responses and could be removed from medication. [cite journal
author = Feingold, Ben F.
title = Hyperkinesis and learning disabilities linked to the ingestion of artificial food colors and flavors
url=http://www.feingold.org/Research/PDFstudies/Feingold76.pdf
journal = Journal of Learning Disabilities
volume = 9
issue = 9
pages = 551–559
date= 1976 November ] [cite journal
author = Feingold, Ben F.
title = Hyperkinesis and learning disabilities linked to artificial food colors and flavors
url = http://www.feingold.org/Research/PDFstudies/Feingold75.pdf
journal = American Journal of Nursing
volume = 75
issue = 5
pages = 797–03
date= 1975 May
pmid = 1039267
doi = 10.2307/3423460]

In 1977, Dr. Arnold Brenner published a study he had begun with the intention of disproving Dr. Feingold's claims. Of 32 children who had been under various medication treatments for years with poor success, and who were now put on the K-P diet, 11 (about 33%) were "markedly improved." Surprised, Dr. Brenner wrote that "the startling changes in patients who had been followed for years with other forms of therapy suggest strongly that this improvement was genuine." [cite journal
author = Brenner, A.
title = A study of the efficacy of the Feingold diet on hyperkinetic children
url = http://www.feingold.org/Research/PDFstudies/Brenner77.pdf
journal = Clinical Pediatrics
volume = 16
issue = 7
pages = 652–656
date= 1977 July
pmid = 862303
doi = 10.1177/000992287701600715] Although 33% does not appear to be a high rate of success, remember that these children had already tried everything else - they were what is called "medication failures."

In the beginning, Dr. Feingold did not eliminate the preservatives BHA or BHT. By 1979, he reported having treated over 600 children with the diet, and that his success rate had risen to 60-70% once he had begun eliminating the preservatives as well. [cite journal
author = Feingold, Ben F.
title = Dietary management of juvenile delinquency
url = http://www.feingold.org/Research/PDFstudies/Feingold-delinq79.pdf
journal = International Journal of Offender Therapy and Comparative Criminology.
volume = 23
issue = 1
pages = 73–84
date= 1979
doi = 10.1177/0306624X7902300108 ] At that time TBHQ and aspartame, which are eliminated today, did not yet exist.

Initial controversy

In late 1972, Dr. Feingold was invited to present his findings at the annual conference of the American Medical Association in June of 1973, which he did. [cite journal
author = Feingold, Ben F.
title = The Role of Diet in Behavior
url = http://www.feingold.org/Research/PDFstudies/Feingold82.pdf
journal = Ecology of Disease
volume = 2
issue = 2/3
pages =153–165
date= 1982
pmid = 6090095] cite journal
author = Feingold, Ben F.
title = A View of the Press From the Other Side
url = http://www.feingold.org/Research/PDFstudies/Feingold-view.pdf
journal = Newspaper Food Editors & Writers Association
date= June 8, 1977] Before that time, he had been treating children and adults with allergy symptoms as well as behavioral symptoms, but by 1972 he had arranged for a group of 25 children with a primary complaint of behavioral problems to be managed by the K-P diet. Dramatic improvement in behavior was repeated in this group as well. Dr. Feingold was again invited to participate in the June 1974 AMA conference, where he reported on 169 children in five separate samples that had experienced a success rate of 30 to 50 percent, depending on the age of the child and the sample. (Note, this was also before the diet eliminated preservatives.)

This led to the first controlled double-blind crossover study, at the University of Pittsburgh, which was funded by the National Institute of Education. It was directed by Dr. C. Keith Connors, with Dr. Feingold as consultant, and the favorable results were published in the August 1976 issue of "Pediatrics", the official publication of the American Academyof Pediatrics. [cite journal
author = Conners CK, Goyette CH, Southwick DA, Lees JM, Andrulonis PA.
title = Food additives and hyperkinesis: a controlled double-blind experiment
journal = Pediatrics |volume=58 |issue=2
pages =154–66
date= August 1976
pmid = 781610]

Meanwhile, in 1974, the food industry became involved via its industry-supported organization called the "Nutrition Foundation of New York."cite journal
author = Feingold, Ben F.
title = A View of the Press From the Other Side
url = http://www.feingold.org/Research/PDFstudies/Feingold-view.pdf
journal = Newspaper Food Editors & Writers Association
date= June 8, 1977] This is an organization whose members included Dow Chemical, Coca Cola, and several companies who make, use, and distribute the food additives removed from the K-P diet [ [http://www.feingold.org/nut.html Feingold Association website: Who is the Nutrition Foundation?] ] . In December, 1974, the Nutrition Foundation issued a "proposal for the study of dietary relationship to hyperkenesis" which promised, in its final paragraph, that "no publicity will be given to the findings until the committee has approved the report for release." A two-week long conference, by invitation only, was arranged in January, 1975, in Glen Cove, Long Island. There, they created what they called the National Advisory Committee (this was not government-related in any way). One week later - and certainly long before any of the planned studies had been done, let alone published - this committee widely published its preliminary report concluding that "no controlled studies have demonstrated that hyperkinesis is related to the ingestion of food additives." cite journal
author = Feingold, Ben F.
title = A View of the Press From the Other Side
url = http://www.feingold.org/Research/PDFstudies/Feingold-view.pdf
journal = Newspaper Food Editors & Writers Association
date= June 8, 1977]

This conclusion is still quoted today, more than 30 years later. [http://www.quackwatch.org/01QuackeryRelatedTopics/feingold.html Quackwatch website page] ] [ [http://www.nncc.org/Nutrition/hyper.html Elisabeth Schafer, Iowa State University Professor, quoted in National Network for Child Care website] ] Adding to the confusion is the assumption that the National Advisory Committee is a governmental agency rather than an arm of industry. Over the next few years, the Nutrition Foundation funded and designed several small studies carefully crafted to show that the diet produced little effect. [cite journal
author = Weiss, Bernard
title = Food Additives and Environmental Chemicals as Sources of Childhood Behavior Disorders
url = http://www.feingold.org/Research/weiss.html
journal = Journal of the American Academy of Child Psychiatry.
date= 1982 Mar
volume = 21(2)
pages = 144–52
pmid = 7069080] cite journal
author = Rimland, Bernard
title = The Feingold Diet: An Assessment of the Reviews by Mattes, by Kavale and Forness and Others
url = http://www.feingold.org/Research/rimland.html
journal = Journal of Learning Disabilities.
date= 1983 Jun-Jul
volume = Jun-Jul 16(6)
pages = 331–3
pmid = 6886554] Although the studies were conducted at universities, which would normally have lent them credibility, Congressman Ben Rosenthal of New York complained, "Despite the compelling need for experts who can examine the food industry with a critical eye, nutrition and food science communities have fallen under the $200 billion industry's influence. At our more prominent universities, eminent nutritionists have traded their independence for food companies' favors." cite journal
author = Feingold, Ben F.
title = A View of the Press From the Other Side
url = http://www.feingold.org/Research/PDFstudies/Feingold-view.pdf
journal = Newspaper Food Editors & Writers Association
date= June 8, 1977]

A review of the early studies published by M.A. Lipton in 1983 cite journal
author=Lipton MA, Mayo JP |title=Diet and hyperkinesis--an update |journal=J Am Diet Assoc |volume=83 |issue=2 |pages=132–4 |year=1983 |month=Aug |pmid=6875141] concluded that possibly 2% of children respond adversely to food additives, and that "even the 2% are questionable." Dr. Lipton further asserted that there "is no need for high-priority research or for changes in public policy regarding the use and labeling of foods containing additives." It should be noted that Dr. Lipton chaired the National Advisory Committee set up by the food industry's Nutrition Foundation discussed above.cite journal
author = Feingold, Ben F.
title = A View of the Press From the Other Side
url = http://www.feingold.org/Research/PDFstudies/Feingold-view.pdf
journal = Newspaper Food Editors & Writers Association
date= June 8, 1977] However, when toxicologist Bernard Weisscite journal | last = Weiss | first = Bernard | year = 1982
title = Food additives and environmental chemicals as sources of childhood behavior disorders
journal = J Am Acad Child Psychiatry. | volume = 21 | issue = 2
pages = 144–152 | url = http://www.feingold.org/Research/adhd.html#Weiss82] and autism expert Bernard Rimlandcite journal | last = Rimland | first = Bernard | year = 1983
title = The Feingold diet: an assessment of the reviews by Mattes, by Kavale and Forness and others
journal = Journal of Learning Disabilities | volume = 16 | issue = 6
pages = 331–333 | url = http://www.feingold.org/Research/rimland.html ] analyzed these same studies, they found that they actually did support the positive effects of the Feingold diet.

Meanwhile, the media had begun calling the K-P Diet the "Feingold Diet," but because of the confusion with weight-loss diets, and because more than just food is involved in the management of ADHD suggested by the Feingold Association, the "Feingold Diet" was renamed the "Feingold Program."

Research findings

Many studies show that 70% or more of hyperactive children respond positively to the removal of synthetic additives, especially when salicylates or allergens are removed., There is controversy, however, over what happens when researchers take children whose behavior has improved on a diet that eliminates several thousand additives, and then challenge them with one or a few additives, usually synthetic colors.

Especially in the early studies, if such a challenge did not produce a change in behavior, researchers often concluded that the diet had not directly caused the initial improvement in behavior. Rather, the assumption was that the improvement had been due to a placebo effect.

There are other possible reasons for the failure of a challenge to evoke a response, however. For example, the amount of additive used as a challenge might have been too small to cause an effect.cite journal
author = Rimland, Bernard
title = The Feingold Diet: An Assessment of the Reviews by Mattes, by Kavale and Forness and Others
url = http://www.feingold.org/Research/rimland.html
journal = Journal of Learning Disabilities.
date= 1983 Jun-Jul
volume = Jun-Jul 16(6)
pages = 331–3
pmid = 6886554] Rowe & Rowe in 1994 found a dose-related effect; the higher the amount of coloring he used for his double-blind challenge, the stronger (and longer) the reaction of the children. cite journal
author=Rowe KS, Rowe KJ
title=Synthetic food coloring and behavior: A dose response effect in a double-blind, placebo-controlled, repeated-measures study
journal=Journal of Pediatrics
year=1994
volume=125
pages=691–698
id =7965420] The following chart lists the amount of coloring used in various studies along with the rate of response:

Considering that in 1976 an FDA scientist estimated that children may be consuming up to 315 mg food dye per day, [http://www.cspinet.org/new/adhd_resch_bk02.pdf Center for Science in the Public Interest, Quarter-Century Review, pg.11] ] all the above studies appear to be overly conservative in their choice of challenge amounts.In addition, the effect of an additive might only be seen in synergy with other additives or foods , or the additive used for the challenge may simply not be among those causing the original effect.

Early studies

Like most new developments, the first reports of improvement of behavior via diet were anecdotal. This was followed by clinical trials and eventually by larger, double-blind placebo-controlled studies.

In 1976, a double-blind crossover diet trial found that both parents and teachers saw fewer hyperkinetic symptoms on the K-P diet as compared to the pretreatment baseline.cite journal
author = Conners CK, Goyette CH, Southwick DA, Lees JM, Andrulonis PA.
year = 1976
month = August
title = Food additives and hyperkinesis: a controlled double-blind experiment
journal = Pediatrics
volume = 58(2)
pages = 154–66
pmid = 781610] A 1978 double-blind crossover study using cookies with 13 mg food dye each combined with either medication or placebo found, "The results of this study offer data that a diet free of artificial flavors and colors results in a reduction of symptoms in some hyperactive children."cite journal
author = Williams JI, Cram DM, Tausig FT, Webster E.
year = 1978
month = June
title = Relative effects of drugs and diet on hyperactive behaviors: an experimental study
journal = Pediatrics
volume = Jun;61(6)
pages = 811–7
pmid = 353680] In 1980, forty children were put on a diet free of artificial food dyes and other additives for five days. They then performed the usual double-blind placebo-controlled test but used 100 mg or 150 mg of the food dye mix. They found that the food dyes impaired the performance of the 20 hyperactive children on paired-associate learning tests. The dyes did not hurt the performance of the 20 non-hyperactive children. The study states: "Our data suggest that a large dose of food dye blend decreases attention span in hyperactive children as reflected by performance on the learning test."cite journal
author = Swanson JM, Kinsbourne M.
year = 1980
month = March
title = Food dyes impair performance of hyperactive children on a laboratory learning test
journal = Science
volume = 28;207(4438)
pages = 1485–7
pmid = 7361102
doi = 10.1126/science.7361102]

Seven small studies adding up to a total of 190 children were published starting in the late 1970s. Some of them were elaborate double-blind diet studies using a Feingold-type diet. In some of these studies, the children were taken off their medication, while in others, they continued on stimulant medications including artificial colorants, in spite of the interference that this would create with the diet.

One of the studies in 1978,cite journal
author = Harley, J.P. and Ray, R.S. and Tomasi, L. and Eichman, P.L. and Matthews, C.G. and Chun, R. and Cleeland, C.S. and Traisman, E.
year = 1978
month = June
title = Hyperkinesis and food additives: testing the Feingold hypothesis
journal = Pediatrics
volume = 61
issue = 6
pages = 818–828
pmid = 353681] for example, used 36 children between 6 and 12, and 10 children between 3 and 5. The teachers of the school-aged children did not record any improvement, but 63% of the mothers reported improved behavior, as well as 100% of the mothers of the preschoolers; however, since the improvement was reported by the parents of the children rather than teachers, and locomotor activity tests were unaffected, it was reported that there was "no diet effect."

In 1980 the Nutrition Foundation set up a review team to review studies related to the Feingold diet.Wender EH, Lipton MA. The National Advisory Committee Report on Hyperkinesis and Food Additives -- Final Report to the Nutrition Foundation. Washington D.C: The Nutrition Foundation, 1980.] They published a report that stated that there was no response at all to the diet. In 1983, the review team's co-chairman and a colleague reviewed a variety of studies and concluded that no more than 2% of children respond adversely to dye additives.

An influential comparative diet study was conducted in 1987 by Gross et al.cite journal
author=Gross, M.D. and Tofanelli, R.A. and Butzirus, S.M. and Snodgrass, E.W.
title=The effect of diets rich in and free from additives on the behavior of children with hyperkinetic and learning disorders
url = http://www.feingold.org/Research/PDFstudies/Gross87.pdf
journal=Journal of the American Academy of Child and Adolescent Psychiatry
year=1987
month = January
volume=26
pages=53–55
pmid = 3584001
doi=10.1097/00004583-198701000-00011] This was a study of 39 children, of whom 18 were hyperactive, and the balance had other learning disorders. Of those 18, all but one were on behavior-modifying medications during the entire study. The researchers provided a Feingold-type diet for a single week that was, by their own description, unpalatable. They particularly noted that the children missed mustard and ketchup; however, mustard is not eliminated by the Feingold diet, and no reason was given for its exclusion.

This diet week was followed by an additive-rich diet the next week. Although the study reported that the camp director and all teachers felt that the children were noisier and more active during the second, additive-rich week, they discounted these observations in favor of filmed 4-minute sequences made during meals. These films were intended to measure reaction to additives in the meals in spite of the fact that any such reaction would not be expected to occur for some time after eating.

During the course of the study, three children were dropped: one who was not on stimulant medication, whose behavior became worse during the second week; one who refused to behave altogether; and one whose dose of Cylert became "inadequate" and whose behavior worsened when additives were allowed during the second week.

They concluded that the "Feingold diet has no beneficial effect on most children with learning disorders" and moreover that the diet was "distasteful to the typical American child."

Later studies

A number of studies conducted since 1980 using diets similar to the Feingold Program report greater than 70% of children responding positively to the diets. Others that eliminated synthetic colors and flavors, but included salicylates still reported greater than 50% positive response.cite journal
author = Egger J, Carter CM, Graham PJ, Gumley D, Soothill JF
year = 1985
title = Controlled trial of oligoantigenic treatment in the hyperkinetic syndrome
journal = Lancet
volume = Mar 9;1(8428)
pages = 540–5
pmid = 2857900
doi = 10.1016/S0140-6736(85)91206-1] cite journal
author = Rowe KS
year = 1988
title = Synthetic food colourings and 'hyperactivity': A. double-blind crossover study
journal = Aust Paediatric Journal
volume = 24
pages = 143¿147
pmid = 3395307] cite journal
author = Kaplan BJ, McNicol J, Conte RA, Moghadam HK
year = 1989
title = Dietary replacement in preschool-aged hyperactive boys
journal = Pediatrics
volume = 83:1
pages = 7–17
pmid = 2909977] cite journal
author = Egger J, Carter CH, Soothill JF, Wilson J.
year = 1992
title = Effect of diet treatment on enuresis in children with migraine or hyperkinetic behavior
journal = Clinical Pediatrics.
volume = May;31(5)
pages = 302–7
pmid = 1582098
doi = 10.1177/000992289203100508] cite journal
author = Carter CM, Urbanowicz M, Hemsley R, Mantilla L, Strobel S, Graham PJ, Taylor E.
year = 1993
title = Effects of a few food diet in attention deficit disorder
journal = Archives of Disease in Childhood.
volume = Nov;69(5)
pages = 564–8.
pmid = 8257176]

In the biggest such study ever performed, published in 1986, the performance of over a million children in 803 New York City public schools was studied for seven years. The children's average standardized test scores rose 8.1% when levels of sucrose (normal table sugar) were restricted to 11 percent along with the removal of two synthetic food colors; when the remaining food colors and all artificial flavors were removed the next academic year, performance rose another 3.8%; when no further changes were made the following academic year, test performance also remained stable; finally, when the petroleum-based preservatives BHT and BHA were removed from the menu in the next academic year, performance improved another 3.7% for an overall improvement of 15.7% in mean national percentile rankings (from 39.2% to 54.9%).cite journal
author = Schoenthaler SJ, Doraz WE, Wakefield JA.
year = 1986
title = The Impact of a Low Food Additive and Sucrose Diet on Academic Performance in 803 New York City Public Schools
journal = International Journal of Biosocial Research
volume = 8(2)
pages = 185–195
url = http://www.feingold.org/Research/research_school.html] Although it appears that improvement increases as the diet approaches the guidelines of the Feingold Program, the researchers suggest that by removing sugar and additives - thereby removing empty calories and processed foods - malnutrition is reduced. It is not clear what portion of the effects can be contributed to limiting sugar intake or the foods containing BHT and BHA (the related preservative TBHQ did not exist at that time) and what portion can be attributed to the removal of the artificial colorants themselves.

A most important and often overlooked detail in this study is that all the children did not improve equally. There was a dramatic decline in learning disabled and repeat-failure children. In 1979, 12.4% of the million children were performing two or more grades below their proper level. By the end of the study in 1983, the percent of children two or more grades below proper level had dropped to 4.9%. Moreover, before the dietary changes, the more school food that was consumed, the worse the children did academically. After the changes, howevr, the more school food the children ate, the better they did academically. cite journal
author = Schoenthaler SJ, Doraz WE, Wakefield J.
year = 1986
title = The Testing of Various Hypothesis as Explanations for the Gains in National Standardized Academic Test Scores in the 1978-1983 New York City Nutrition Policy Modification Project
journal = The International Journal of Biosocial Research.
volume = 8(2)
pages = 196–203.]

In 1997, an association between brain electrical activity and intake of provoking foods was shown in children with food-induced ADHD. ( [http://www.feingold.org/Research/uhlig-pic.html Picture] )cite journal
author = Uhlig T, Merkenschlager A, Brandmaier R, Egger J.
year = 1997
title = Topographic mapping of brain electrical activity in children with food-induced attention deficit hyperkinetic disorder
journal = European Journal of Pediatrics.
volume = Jul;156(7)
pages = 557–61
pmid = 9243241
doi = 10.1007/s004310050662] Another study showed that an oligoantigenic diet can work as well as Ritalin for conduct-disordered children.cite journal
author = Schmidt MH, Mocks P, Lay B, Eisert HG, Fojkar R, Fritz-Sigmund D, Marcus A, Musaeus B.
year = 1997
title = Does oligoantigenic diet influence hyperactive/conduct-disordered children--a controlled trial
journal = European Child & Adolescent Psychiatry.
volume = Jun;6(2)
pages = 88–95
pmid = 9257090] Other research demonstrated the positive effect of treating young criminals with dietary intervention and correction of mineral imbalances,cite journal
author = Peter C, Bennett W, Brostoff J.
year = 1997
title = The Health of Criminals Related to Behaviour, Food, Allergy and Nutrition: A Controlled Study of 100 Persistent Young Offenders
journal = Journal of Nutritional & Environmental Medicine.
volume = Vol.7, No.4 Dec 1997
pages = 359–366
url = http://www.feingold.org/Research/PDFstudies/Peter97.pdf
doi = 10.1080/13590849762493] cite journal
author = Peter C, Bennett W, McEwen, LM, McEwen HC, ROSE, EL.
year = 1997
title = The Shipley project: Treating food allergy to prevent criminal behavior in community settings
journal = Journal of Nutritional & Environmental Medicine.
volume = Vol.8, No.1,Mar.1998
pages = 77–8
url = http://www.feingold.org/Research/PDFstudies/Peter98.pdf] and that toddlers show both significant reductions in hyperactive behaviour when additives are removed from their diet, as well as increased hyperactivity when exposed to a very small (20 mg) amount of food coloring and a benzoate preservative. This effect was observed by parents whether or not the child was hyperactive or atopic.cite journal
author = Bateman B, Warner JO, Hutchinson E, Dean T, Rowlandson P, Gant C, Grundy J, Fitzgerald C, Stevenson J.
year = 2004
title = The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children
journal = Archives of Disease in Childhood.
volume = Jun;89(6)
pages = 506–11
pmid = 15155391
doi = 10.1136/adc.2003.031435]

A 2007 British study at the University of Southamptoncite journal
author=McCann D, Barrett A, Cooper A, "et al" |title=Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial |journal=Lancet |volume=370 |issue=9598 |pages=1560–7 |year=2007 |month=Nov |pmid=17825405 |doi=10.1016/S0140-6736(07)61306-3] has pointed to food additives as a health hazard for all children, whether they have ADHD or not. The study concluded that artificial colors or a sodium benzoate preservative (or both) in the diet result in increased hyperactivity in 3-year-old and 8/9-year-old children in the general population. In response to this study and a massive media and grass-roots campaign, the major supermarket chains in the UK have removed additives from their house brands. Several American-based candy companies have done the same with the candies they sell in the UK.

Anne Swain, of the Allergy Unit at Royal Prince Alfred Hospital in Sydney Australia, measured amounts (but not type) of salicylate in 333 foods in 1985,cite journal
author = Swain AR, Dutton SP, Truswell AS
year = 1985
title = Salicylates in foods.
journal = Journal of the American Dietetic Association. |month=Aug |volume=85 |issue=8
pages = 950–60.
pmid = 4019987] and has done other research based on the Feingold Diet.cite web
title=Food Intolerance Network
url=http://www.fedupwithfoodadditives.info/information/Swain%20et%20al%201985.pdf
accessdate=2008-03-31] The Australian version of the Feingold diet, called Failsafe, is far more restrictive than the Feingold Program, but claims to be highly effective, particularly for children with high aggression levels.cite web
author=Sue Dengate
title=Food Intolerance Network
url=http://www.fedupwithfoodadditives.info/
accessdate=2008-03-31]

Criticism of Feingold diet

Over the years, a number of criticisms of the Feingold Program have been presented. Many of these center on the difficulty in avoiding synthetic additives, especially in processed or fast food or while eating out, or with social or emotional side-effects the diet may cause. Others center on the range of symptoms claimed to be improved by the Feingold Program.

Food- and diet-related issues

Some critics say that the Feingold Program requires a significant change in family lifestyle and eating patterns because families are limited to a narrow selection of foods, and that such foods are often expensive, and must be prepared "from scratch", greatly increasing the amount of time and effort a family must put into preparing a meal. However, the Feingold Association publishes a "Foodlist & Shopping Guide" that provides thousands of acceptable brand-name items to choose from, including many convenience foods available in their local supermarkets. They also provide a "Fast Food & Restaurant Guide" as well as other help.

Like any change in diet, the Feingold Program does require that patients make changes in the food that they eat. However, these changes do not usually require significant changes in the types or cost of food a family may choose or the way a family chooses to prepare them. Such choices can be more difficult when little is known about the exact ingredients used in a product, such as at a restaurant or when purchasing food from a vending machine. This requires that a family identify restaurants or products that are not likely to create a problem. Questionable choices can also be avoided by bringing appropriate food when necessary, such as bringing a lunch to school. Parents are encouraged to keep treats available at home and school, so that the children never need feel deprived or left out.]

Nutritionally, the Feingold Program is little different from a normal diet. While some fruits and a few vegetables are eliminated in the first weeks of the Program, they are replaced by others. Often, some or all of these items can be returned to the diet, once the level of tolerance is determined. Studies have found that children on the Feingold Program actually ate better than those eating a "usual" diet, and were more likely to achieve the Recommended Dietary Allowance (RDA) of various nutrients.cite journal
author = Dumbrell, S. and Woodhill, J.M. and Mackie, L. and Leelarthaepin, B.
year = 1978
month = December
title = Is the Australian version of the Feingold diet safe?
journal = The Medical Journal of Australia
volume = 2
issue = 12
pages = 569–570
pmid = 364258] cite journal
author = Harper, P.H. and Goyette, C.H. and Conners, C.K.
year = 1978
month = November
title = Nutrient intakes of children on the hyperkinesis diet
journal = Journal of the American Dietetic Association
volume = 73
issue = 5
pages = 515–519
pmid = 701681]

Psychological or behavioral issues

Other critics express concerns about social or emotional effects of putting children on a specific diet. These include that their self esteem may be undermined by implanting notions that they are unhealthy and fragile, or that children may experience situations in which the children's eating behavior or "fear of chemicals" are regarded as peculiar by other children.

No clinical evidence supports these speculations, although the attitude of the parents may be important. The issues that a child on the Feingold Program faces are very similar to the issues that a child with an allergy to a common product such as eggs or peanuts must deal with, or a medical condition such as diabetes. Compared to these situations, the Feingold Program could be seen as relatively liberal, as it includes sugary foods, junk foods and even fast food.

Treating multiple symptoms

Some feel that it is absurd to think that one intervention could improve symptoms as diverse as asthma, allergies, bedwetting, chronic ear infections, headaches, and insomnia all at once. Critics point to the fact that effectiveness against a wide range of unrelated symptoms is frequently a hallmark of treatments that work via the placebo effect.

The diet was originally designed as a diagnostic elimination diet to improve food-related asthma and allergic reactions and was only later found to also be effective in treating behavioral issues. In addition, many children with ADHD suffer from multiple comorbid symptoms. It has been found that there is a profile of the child most likely to benefit from the diet.cite web
author=The Feingold Association of the United States
title=Feingold Program - Symptoms
publisher=The Feingold Association of the United States
year=2006
work=The Feingold Association website
url=http://www.feingold.org/symptom-pg.html
accessdate=2006-08-21] The child may not have all of these symptoms: some may have few symptoms and others seem to have all of them. While the underlying physiological reason is not understood, when a patient eliminates the additives to which they are sensitive, many or even most of the symptoms contained within the profile are improved. Research supports dietary intervention for each of the symptoms in turn.cite journal
author = Schab DW, Trinh NH.
year = 2004
month = Dec.
title = Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind placebo-controlled trials
journal = Journal of Developmental and Behavioral Pediatrics
volume = 25(6)
pages = 423–34
pmid = 15613992
doi = 10.1097/00004703-200412000-00007] cite journal
author = Jiménez-Aranda GS, Flores-Sandoval G, Gómez-Vera J, Orea-Solano M.
year = 1996
month = Nov-Dec
title = Prevalence of chronic urticaria following the ingestion of food additives in a third tier hospital
journal = Revista Alergia Mexico
volume = 43(6)
pages = 152–6
pmid = 9053127] cite journal
author = Egger J, Carter CH, Soothill JF, Wilson J.
year = 1992
month = May
title = Effect of diet treatment on enuresis in children with migraine or hyperkinetic behavior
journal = Clinical Pediatrics
volume = 31(5)
pages = 302–7
pmid = 1582098
doi = 10.1177/000992289203100508] cite journal
author = Schmidt MH, Möcks P, Lay B, Eisert HG, Fojkar R, Fritz-Sigmund D, Marcus A, Musaeus B.
year = 1997
month = June
title = Does oligoantigenic diet influence hyperactive/conduct-disordered children--a controlled trial.
journal = European Child & Adolescent Psychiatry
volume = 6(2)
pages = 88–95
pmid = 9257090] cite journal
author = Novembre E, Dini L, Bernardini R, Resti M, Vierucci A.
year = 1992
month = Jan-Feb
title = Unusual reactions to food additives
journal = Medical and Surgical Pediatrics
volume = 14(1)
pages = 39–42
pmid = 1579515] cite journal
author = Wasowka-Królikowska K, Dynowski J, Godzisz J.
year = 1998
month = Dec.
title = The way of nutrition and frequency of otitis media in hospitalized infants and 3-year-old children
journal = Polski Merkuriusz Lekarski
volume = 5(30)
pages = 333–4
pmid = 10101517] cite journal
author = Moneret-Vautrin DA.
year = 2003
month = May
title = Allergic and pseudo-allergic reactions to foods in chronic urticaria
journal = Annales de dermatologie et de vénéréologie.
volume = 130 Spec No 1
pages = 1S35–42
pmid = 12843808] cite journal
author = Feingold BF.
year = 1979
title = Dietary management of nystagmus
journal = Journal of Neural Transmission
volume = 45(2)
pages = 107–15
pmid = 469522
doi = 10.1007/BF01250086] cite journal
author = Inomata N, Osuna H, Fujita H, Ogawa T, Ikezawa Z.
year = 2006
month = June
title = Multiple chemical sensitivities following intolerance to azo dye in sweets in a 5-year-old girl
journal = Allergology International
volume = 55(2)
pages = 203–5
pmid = 17075259
doi = 10.2332/allergolint.55.203] cite journal
author = Spector SL, Wangaard CH, Farr RS.
year = 1979
month = Dec.
title = Aspirin and concomitant idiosyncrasies in adult asthmatic patients
journal = Journal of Allergy & Clinical Imunology
volume = 64(6 Pt 1)
pages = 500–6
pmid = 512268
doi = 10.1016/0091-6749(79)90059-9] cite journal
author = Egger J, Carter CM, Soothill JF, Wilson J.
year = 1989
month = Jan.
title = Oligoantigenic diet treatment of children with epilepsy and migraine
journal = The Journal of Pediatrics
volume = 114(1)
pages = 51–8
pmid = 2909707
doi = 10.1016/S0022-3476(89)80600-6] cite journal
author = Kaplan BJ, McNicol J, Conte RA, Moghadam HK.
year = 1989
month = Jan.
title = Dietary replacement in preschool-aged hyperactive boys
journal = Pediatrics
volume = 83(1)
pages = 7–17.
pmid = 2909977]

upport for parents

Dr. Feingold wrote a book directed to parents, entitled "Why Your Child is Hyperactive." [cite book | author=Feingold, B.F. | title=Why Your Child is Hyperactive
publisher=Random House | year=1985 | id=ISBN 0-394-73426-2] , as well as "The Feingold Cookbook", [cite book | author=Feingold, B.F.
title=The Feingold Cookbook for Hyperactive Children | publisher=Random House
year=1979 | id=ISBN 0-394-73664-8] written in collaboration with his wife, Helene. In addition, more up-to-date books have also been published.

As parents began using this diet for their children, many saw dramatic success and formed grass roots support groups. When they gathered in 1976 to form a non-profit national organization, they chose the name "Feingold Association" to honor Dr. Feingold. As time passed, due to the increasing number of double-income families, fewer mothers were available to run these local "kitchen table" support groups, and today the Feingold Association of the United States provides member support services. Recently, some support has been added for Canadian members, and there is some information on the website suitable for people in other countries, as well.

The Feingold Association provides information and support for those starting the Program. Members receive comprehensive materials cite web
author=The Feingold Association of the United States
title=The Feingold Program
publisher=The Feingold Association of the United States
year=2006
work=The Feingold Association website
url=http://www.feingold.org/materials-pg.html
accessdate=2006-04-29] including a book listing thousands of brand name foods that have been researched by the Association and are free of the eliminated additives. Newsletters, updates, and phone and email support are also provided. Acceptable products — food, toiletries, cleaning supplies — are included in the "Foodlist and Shopping Guide", the "Mail Order Guide", the "Supplements Guide" and the "Fast Food Guide".

A good introduction to the Feingold Program, as well as 400 pages of compiled wisdom from over 30 years of working with families using the diet, is provided by the book [http://www.feingold.org/book.html "Why Can't My Child Behave?"] cite book
last = Hersey
first = Jane
coauthors = Robert C. Lawlor
year = 2006
edition = 4th printing
title = Why Can't My Child Behave?
publisher = Pear Tree Press
location = Williamsburg, VA
id = ISBN 0-9651105-0-8
url = http://www.feingold.org/book.html]

References

External links

* [http://www.feingold.org/ The Feingold Association website]
* [http://odp.od.nih.gov/consensus/cons/110/110_statement.htm NIH Consensus Statement on ADHD] 1982
* [http://www.annalsonline.org/cgi/content/abstract/931/1/310 "Alternative Treatments for Adults with Attention-Deficit Hyperactivity Disorder"] by L.E. Arnold in the Annals of the New York Academy of Sciences
* [http://www.pediatrics.org/cgi/content/abstract/105/5/1158 American Academy of Pediatrics Guideline for Diagnosis and Evaluation of the Child With ADHD] 2000