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Summary of The Feingold Diet

Most of these additives are synthetic compounds made from by-products of the petroleum refining process. The word "synthetic" is used instead of "artificial" because some artificial colorings such as titanium dioxide are not eliminated by the program. Only FD&C and D&C certified colorings are eliminated.

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.

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 common temperate-zone fruits, as well as a few vegetables, spices, and one tree nut. During this early period (Stage One), 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.

The Feingold Association provides information and support for those starting the Program. Members receive comprehensive materials [3] 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 "Why Can't My Child Behave?"


History

Dr. Feingold was a pediatrician and allergist, and was considered a pioneer in the fields of allergy and immunology. 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). Dr. Stephen Lockey 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 his patients.

The first clear case was a patient referred to him for treatment of her severe hives in 1965.  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 under treatment for a personality disorder for years, but in less than two weeks on the diet, her behavior had noticably 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 but 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). Later, as this diet became more well-known for helping hyperactive and learning disabled children, the media dubbed it the "Feingold diet."


Beginning of the ADHD Epidemic

Some of Dr. Feingold's patients in the 1960's were children with asthma, hives, or other allergies. Increasingly, they also suffered from behavioral problems which appeared to resolve upon treatment with the K-P diet.

By the 1970's, pediatricians in the United States were becoming alarmed by the growing number of children they saw who had difficulty behaving, focusing and functioning normally.

Doctors like Dr. Feingold — old enough to remember the 1920's and 1930's — were aware that ADHD (at various times also called hyperkinesis, hyperactivity, or minimal brain dysfunction/MBD) was at one time rare. What had happened? It is often stated that ADHD is genetic, but it is impossible to have an epidemic of a genetic disorder unless something has happened in the environment to interact with some gene combination that had not caused problems before. A typical example would be the epidemic of diabetes in the Native American population: Diabetes was not a problem until the Native Americans changed from their original lifestyle and diet to a more sedentary lifestyle and Western diet.


What changed in the (dietary) environment?

During World War II, the United States needed to preserve food to feed its troops scattered all over the world — BHA and BHT made from petroleum became the useful, cheap, preservative of choice. For energy, soldiers needed a chocolate candy that would not melt in the jungle — M&M's with candy shells colored with coal tar dyes (now made from petroleum) filled this need.

World War II was a watershed; after the war, as technology increased, manufacturers realized that they could save money by substituting low-cost food additives to replace natural ingredients. The raw whole food could now be mashed, extruded, reformatted, shaped, colored, flavored, etc., to the specifications of the marketer.

For example, before 1900, gelatin desserts were made with gelatin and fruit juice. By World War II, however, they were mass produced from pure gelatin with added flavorants and colorants, and no fruit juice at all.

By the end of World War II, the food supply had changed, and the use of synthetic additives had increased dramatically. Over the next years, as these products became household staples, this increase paralleled the increase of hyperkinesis (ADHD).


Early Use of the K-P / Feingold Diet

As he began to form a hypothesis around the connection between food additives and hyperkinesis, Dr. Feingold began to look for children that had not responded to typical treatments such as Ritalin, Dexedrine, Talk Therapy or other available treatmemts. He offered them the K-P diet. He reported the following response to the diet in children for whom other tpical approaches had failed[citation needed]:

* 1/3 significantly helped
* 1/3 partially helped
* 1/3 not helped

Since these families had already tried a variety of other medications and treatments without improvement, they were not likely to be placebo-responders.

In the beginning, Dr. Feingold did not eliminate the preservatives BHA or BHT. After food additive expert and author Beatrice Trum Hunter convinced him to do so, his results increased dramatically to over 70% success[citation needed]. At that time TBHQ and aspartame, which are eliminated today, did not yet exist.


AMA Presentation and Followup

In 1973, Dr. Feingold was invited to present his findings at the annual conference of the American Medical Association. By that time he had 8 years of clinical experience with the diet: he had treated hundreds of children, and was beginning to use this experience to develop a more user-friendly diet. The AMA was impressed and excited with his findings. They set up press conferences with Dr. Feingold all over the United States to discuss his findings, and articles about his work appeared in newspapers all over the world[citation needed].

The Nutrition Foundation, 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, offered to design and fund research on the diet, promising not to publish any opinions until they had done so. Within a few months, though, in spite of the fact that the promised research had not yet been done, the Nutrition Foundation published statements claiming that there was "no valid scientific support"[cite this quote] for the K-P diet. These statements are still quoted today, more than 30 years later[citation needed].

The AMA abruptly dropped its support without explanation [citation needed]. Dr. Feingold's requests to speak at conferences were turned down [citation needed]. Over the next few years, the Nutrition Foundation funded and designed several small studies carefully crafted to show that the diet produced little effect.

One such review of these studies published in 1983 concluded that maybe 2% of children respond adversely to food additives, but that even the 2% was "questionable," and that there was no need for further research on additives or for any improvement in product labeling. However, when toxicologist Bernard Weiss  and autism expert Bernard Rimland  analyzed these same studies, they found that they actually did support the positive effects of the Feingold diet.


Finding another way

After the AMA's change of heart, Dr. Feingold agreed to write a book that would be directed to parents. Random House named the book Why Your Child is Hyperactive.  It was first published in 1975, followed four years later by The Feingold Cookbook,  written in collaboration with his wife, Helene. Although these books are of historical interest, the information they contain is out of date, so they are not recommended by the Feingold Association to be used as guides to the diet.

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.

Because of the confusion with weight-loss diets, and because more than just diet is involved in the management of ADHD suggested by the Feingold Association, the "Feingold Diet" was renamed the "Feingold Program."


Research findings

Most studies, both old and new, show that about 70% of the children respond positively to the removal of synthetic additives - even more when salicylates and/or allergens are removed. There never has been controversy over this. The controversy involves what happens when the 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 colorants.


In the early studies, if such a "challenge" did not produce deterioration, the researchers concluded that the "diet" had not "worked," the assumption being that the improvement on the open diet had been due to a placebo effect. Other possible reasons for the failure of a challenge to evoke a response could, however, be that the challenge amount is too small, or because it only causes problems when used in combination with some other additive or food (a synergistic effect), or simply because the additive used for the challenge was not among those causing the original effect.

A graphic comparison of studies using food dyes as the challenge (click on Graph 1 at right to enlarge) shows that there is actually a dose-related response; when more is used, more children react to it. This indicates that the choice of synthetic coloring as a challenge material is appropriate, but that those studies that did not show a response did not use enough.

Abstracts of clinical studies, laboratory studies, reviews, etc. can be found, with links to MedLine, at the diet studies website.


Early studies

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

The following quotes are from some well-known studies done at that time:

* In 1976 Conners et al reported that in a double-blind crossover diet trial, both parents and teachers saw fewer hyperkinetic symptoms on the K-P diet as compared to the pretreatment baseline. Conners said, "The results of this study strongly suggest that a diet free of most natural salicylates, artificial flavors, and artificial colors reduced the perceived hyperactivity of some children suffering from hyperkinetic impulse disorder."

* In a 1978 double-blind crossover study using cookies with only 13 mg food dye each, combined with either medication or placebo, Williams et al reported, "There is evidence, particularly in teacher ratings, in support of Feingold's hypothesis if it is modified." (He used a Feingold-type diet but did not eliminate salicylates.) Again, in his Discussion section, he said, "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.

* In 1980, Swanson & Kinsbourne put forty children on a diet free of artificial food dyes and other additives for five days. Then they did 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 - but not the placebo - impaired the performance of the 20 hyperactive children on paired-associate learning tests. The dyes did not hurt the performance of the 20 nonhyperactive children. Swanson reported, "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."

* In 1982, Shaywitz reported on a study of rat pups which were given food dyes at .5 mg/kg, calculated to be equivalent to half the average daily intake (1 mg/kg) of food dyes by American children. The rats took more than twice as long to escape from a maze that they had already learned. Shaywitz said, "Our results provide additional support for the belief that administration of food colorings may exert significant effects in the developing organism."  In 2002, students at Mercer University determined that it takes about 150 mg (a generous pinch) of powdered coloring to turn one tablespoon of ketchup green, and 18 mg of Red #40 per 6 oz cup to match the color of red Koolaid. [citation needed] It takes 1 Tb of ketchup to cover a hamburger, and at least one more for the French fries. Thus, a child weighing 20 kg (about 44 lb) may eat more than 300 mg of food dye at lunch, plus about another 40 mg in his 12 oz drink. This translates to 15 mg/kg, or over 30 times the amount used by Shaywitz. No study has ever been done on children with that amount of food dye.

Seven small studies adding up to a total of 190 children were funded and designed by the Nutrition Foundation. These studies were published in the late 1970's.

Some of them were elaborate double-blind diet studies, using a Feingold-type diet and a control diet containing 27 mg food dyes and, usually, some unlisted salicylates of unknown quantity. 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 obvious interference that would have with any effect of the diet.

One of the studies by Harley and co-workers  in 1978, for example, used 36 children between 6 and 12 (enrolled in primary education), and 10 children between 3 and 5. The teachers of the school children did not record any improvement, but 63% of the mothers reported better behavior on the Feingold diet. The mothers of all ten of the pre-schoolers (100%) reported improved behaviour on the Feingold diet. However, since the improvement was reported by the parents of the children (no teachers were involved), and locomotor (movement) activity tests were negative, he reported that there was "no diet effect."

In 1980 the Nutrition Foundation set up a "review team" to review studies on the Feingold diet. First, they published a report 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. Continuing to quote this report today, physicians, psychologists, and even government agencies maintain that the percentage of children who may become hyperactive in response to food additives is, at best, very small.

One of the last of the comparative diet studies was the 1987 study by Gross and co-workers.

Since this study has sometimes been cited as "the definitive study on the Feingold diet," it pays to look at it in detail.

* This was a study of 39 children, of whom only 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.
* Three children were dropped from the study: One 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.
* Although the researchers used an isolated summer camp milieu to prevent cheating, it is not recorded whether they addressed additives and colorants in medications, toothpaste, cleaning supplies, etc.
* The researchers provided a "Feingold" diet for a single week that was, by their own description, unpalatable, but did not tell the children it was a diet. Instead, they told the children that the foods they wanted were on order but had not yet arrived, thus encouraging a negative attitude and feelings of deprivation. They particularly noted that the children missed mustard and ketchup; mustard is, however, not eliminated by the Feingold diet, and no reason was given for its exclusion.
* This "Feingold" diet week was followed by an "additive-rich" diet the next week. The researchers acknowledged that a one week diet trial is short, but defended it by saying that allergic reactions appear minutes to hours after exposure, and by the fact that people already using the Feingold diet say that eating something "off-diet" causes a reaction within a few hours. They ignored Feingold's instructions that when starting the diet no change is expected, usually, until after one to several weeks (Feingold, 1974).

* Although reporting that the camp director and all teachers felt the children were noisier and more active the second (additive-rich) week, they discounted these observations in favor of carefully filmed 4-minute sequences made during meals. These films were intended to measure reaction to additives in the meals in spite of the obvious fact that any such reaction could not be expected for several hours.
* They concluded that the "Feingold diet has no beneficial effect on most children with learning disorders...." and moreover that it was "distasteful to the typical American child."



Later studies

Like the earlier studies, recent studies show that an average of 75% of children improve on an additive-restricted diet; results vary between 50% to 85% depending on how close the test diet is to the Feingold Program. For example, in a 1994 study of 200 children by Rowe & Rowe, 75% of the children improved on a Feingold-type diet; more than 82% of them got worse in a double-blind challenge using small-to-modest amounts of the single food dye, Tartrazine (Yellow #5), and a dose-response effect was observed.

In the biggest such study ever done, Schoenthaler studied the performance of over a million children in 803 New York City public schools for seven years. The children's average standardized test scores rose 15.7% during the years that additives were removed from their breakfast and lunch menus (See graph).

In 1997, N.I. Ward, a British chemist, reported that "...Only hyperactive children showed a significant reduction in blood serum zinc levels and an increase in urinary zinc output following the consumption of E102 [tartrazine] and E110 [sunset yellow].

Also in 1997, Uhlig was the first one to show an association between brain electrical activity and intake of provoking foods in children with food-induced attention deficit hyperactivity disorder. (See picture)  and Schmidt, in Germany, showed that dietary intervention works as well as methylphenidate (Ritalin) for conduct-disordered children.  Meanwhile, in England, researchers demonstrated the feasibility of treating young criminals with dietary intervention and correction of mineral imbalances,  and Bateman, in 2004, showed that toddlers show significant reductions in hyperactive behaviour when additives are removed from their diet, with increased hyperactivity when exposed to a very small (20 mg) amount of food coloring and some benzoate preservative. The effect was observed by parents whether or not the children were hyperactive or atopic.

In other studies, Reyes (1996) found that all food colors he tested inhibited mitochondrial respiration. Since mitochondrial respiration is important in the control of energy metabolism,  more studies on this should be done.

Other studies using Feingold-type diets, and published in MedLine since 1980, report the following percentage of children responding to the diets - significantly more than the 2% claimed by Lipton and the Nutrition Foundation.


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.


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 [citation needed].

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. It does require making careful selections between similar alternatives, rather than wholesale changes.[citation needed] To assist with this, the Feingold Association publishes the Foodlist & Shopping Guide books several times a year, which provides a list of brand-name products available to U.S. and Canadian shoppers that conform to the guidelines, including a wide variety of processed food items.

Such choices can be more difficult to make in circumstances where 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. To assist with this, the Feingold Association provides a Fast Food Guide and suggestions for choosing restaurant foods. 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.[citation needed]

Nutritionally, the the Feingold Program is little different from what the child would experience without it. 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.


Psychological or Behavioral Issues

Other critics express concerns about social or emotional side-effects that putting children on a specific diet may have. 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. Some have even gone so far as to speculate the Feingold Program could contribute to a child developing an eating disorder in later life.[43]

No clinical evidence whatsoever supports these speculations. While it is possible to use any therapy abusively, this is obviously not the intention of the Feingold Program. Children can continue to enjoy the same circumstances and experiences any other child would, and at the same time avoid the additives that trigger their symptoms.

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 lactose or peanut butter must deal with, or a condition such as diabetes. With that perspective, a child on the Feingold Program would hardly stand out as "different." In fact, the Feingold Program could be seen as relatively liberal, as it includes sugary foods, junk foods and even fast food.




Multiple symptoms improved

Citing the Feingold Program symptoms list, Critics claim 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. Furthermore, effectiveness against a wide range of unrelated symptoms is frequently a hallmark of treatments that work via the placebo effect.


Proponents of the Feingold diet, however, make the following points in rebuttal:

* The diet was originally designed as a diagnostic elimination diet for asthma and allergies, so it is not surprising that it influences these problems.
* The research section of the Feingold Association website has references to research articles supporting dietary intervention for each of the symptoms in turn. The studies are linked to their sources in MedLine.
* Many children with ADHD have multiple symptoms, and indeed there is a group of symptoms that forms a profile of the child most likely to benefit from the diet. The interlocking circles graphic of comorbid (those existing at the same time) conditions depicts this situation: The person benefiting from the Feingold Program may fall anywhere within these circles; some have few symptoms and others seem to have all of them. When additives are the problem, their removal improves all or most of the person's symptoms.



Risk/Benefit Analysis

In any treatment being considered, the potential benefits should be weighed against the potential harm. The theoretical risks have been discussed at length in the section above. For 10 to 25 percent of children, the diet may not help at all, which can be frustrating for a parent trying their best - but then no therapies work for everyone.

Among potential benefits of using the Feingold Program are the following:

* It is a diagnostic test. If the child (or adult) improves, then it can also be used as the treatment.
* There are no adverse side effects, as are experienced with medications.
* Unlike the stimulant and antidepressant medications promoted for treatment of ADHD, diet therapy does not require a "black box" warning of severe or life-threatening side effects.
* It is probably the least costly of all available treatments for ADHD.
* Liver function tests, blood tests, EKG's, EEG's, and blood pressure testing are not required for the Feingold Program, although if they are required because of some other medical condition, the diet will not interfere.
* Many of the additives avoided are carcinogenic, so it is wise to avoid them in any case.
* Studies have shown that children on the Feingold Program are more likely to get the Recommended Dietary Allowances (RDA) of nutrients than other children.
* The diet is flexible enough to accommodate those on a diabetic diet, a low-carbohydrate diet, a vegetarian or vegan diet, an allergy or gluten-free diet, or an "American" diet (even including some fast foods).
* Taking charge of one's own health is a good thing for a child to learn.
* Learning to say no to foods with additives may help a child say no to recreational drugs later on.
* If the diet is successful, the family may save a lot of money by no longer needing special schools, attention from medical specialists, expensive medications, etc.
* Some children may still need medication, supplements, school accommodation, behavior modification, or other intervention in addition to diet. If using medication, a much lower dose may be needed. The research to explain this has not been done, but a clue was provided by a study using the computerized Test of Variables of Attention (TOVA), which measures 4 parameters in sets of 2. Use of stimulant medication initially impacts one set of TOVA parameters, while use of the diet initially impacts the other set. All four parameters (both sets) must approach normal before a change in behavior is apparent.