Long-Term Effects of an Oligoantigenic Diet in Children with Attention-Deficit/Hyperactivity Disorder (ADHD) on Core Symptomatology

In the early 1920s, it was discovered that nutrition is associated with what is known today as Attention-Deficit/Hyperactivity Disorder (ADHD) and that certain foods can worsen the symptoms. In previous studies, approximately 60% of the participants experience at least a 40% reduction in ADHD symptoms after an oligoantigenic diet (OD). The purpose of this study was to evaluate ADHD symptoms in children approximately 3.5 years after completing a 4-week oligoantigenic diet. Among 28 participants who completed the 4-week diet, 21 were re-assessed for this study after 3.5 years. The severity of ADHD symptoms was assessed with the ADHD-Rating-Scale-IV (ARS). Of 21 participants, 14 fulfilled the responder criterion, whereas 7 did not. At follow-up, 28% of the participants were taking medication. The mean ARS total score improved significantly from T1: M = 29.62 (SD = 9.80) to T2: M = 15.86 (SD = 8.56) between the time points before and after the diet (d = −1.91). There was also a lower ARS total score at the follow-up T5: M = 16.00 (SD = 10.52) compared to before the diet (d = −1.17). This study shows that individually adjusted nutrition significantly improved the ADHD symptomatology of the participants long-term. This suggests that an oligoantigenic diet with subsequent individual nutritional recommendations could become an additional treatment option for children with ADHD.     

The influence of components of diet on the symptoms of ADHD in children

In most children with ADHD the cause of the disease is not exactly known, and its etiology is multifactorial. The conventional treatment is based on the combination of behavioral and psychological therapy and the pharmacotherapy. The pharmacotherapy has a high effectiveness in ADHD treatment, but it is often associated with undesirable side effects, such as: loss of appetite and weight, growth inhibition, abdominal pain, headaches, sleeping problems and increased blood pressure. In the recent years, much attention was devoted to the issue of an appropriate diet in this disease, especially when the standard pharmacotherapy is not effective. The diet of pregnant and lactating woman, and child may have an impact on the development and deepening of the hyperkinetic syndrome. There is much evidence to indicate that it is linked to nutritional factors. Chronic deficiencies of certain minerals such as zinc, iron, magnesium and iodine and insufficient dietary intake of long-chain polyunsaturated fatty acids may have a significant impact on the development and deepening of the symptoms of ADHD in children. A crucial role in the diet of pregnant and lactating women, and child plays also polyunsaturated omega-3 fatty acids, mainly DHA, which are necessary for proper development and function of brain. Their chronic deficiency may contribute to increase risk of ADHD in children. The authors of several studies also demonstrated the positive impact of the elimination food products containing synthetic food additives, like artificial food dyes and preservatives on the behavior of children with ADHD. The beneficial effects brought also the elimination of food products, that are rich in salicylates. It was found that the intake of food products with a low glycemic index helps to reduce symptoms in some hyperactive children. Providing an appropriate supply of nutrients and minerals and elimination of certain food products from diet is especially important during intensive growth and development of the child. In this article the issues concerning the role of the diet in treatment of the children with diagnosed ADHD and the importance of deficiency of certain minerals and long-chain polyunsaturated fatty acids in pregnancy and child growth was discussed. There is a need for further studies in this area to evaluate the potential effectiveness of the diet in treating the symptoms of ADHD.     

Dietary assessment in children adhering to a food allergen avoidance diet for allergy prevention

OBJECTIVE: The purpose of this investigation was to verify if avoidance of allergenic foods in children adhering to a food allergen avoidance diet from birth was complete and feasible, and whether dietary assessment can be used as a tool in predicting the outcome of double-blind, placebo-controlled food challenges (DBPCFCs). DESIGN: Children adhering to an allergen avoidance diet from birth underwent DBPCFCs. The investigator-dietician verified whether the elimination was complete, using food frequency questionnaires for common allergenic foods. SETTING: University Medical Centre Groningen, the Netherlands. SUBJECTS: Thiry-eight children aged 1-13 years, who were consecutively referred to the University Medical Centre Groningen for DBPCFC between January 2002 and February 2004. RESULTS: Among the 38 children undergoing DBPCFCs, there were 15 challenges with egg, 15 with peanut, five with hazelnut and three with soy. Fifteen food challenges (39%) were positive. Small quantities of allergenic foods were inadvertently present in the diets of 13 patients (34%), were possibly present in the diets of 14 patients (37%) and could not be identified in the diets of 11 patients (29%). Seven patients (54%) who had inadvertently ingested small quantities of allergenic foods without sequelae had a positive DBPCFC. CONCLUSION: Dietary avoidance was incomplete and not feasible in most cases. Tolerance of small amounts of allergenic foods does not preclude positive challenge reactions. Dietary assessment does not seem a useful tool in predicting the outcome of DBPCFC in children adhering to an elimination diet. SPONSORSHIP: The Stichting Astma Bestrijding (Foundation for the Prevention of Asthma), The Netherlands.     

Child and Parent Perceived Food-Induced Gastrointestinal Symptoms and Quality of Life in Children with Functional Gastrointestinal Disorders

It is unknown whether children with functional gastrointestinal (GI) disorders identify specific foods that exacerbate their GI symptoms. The objectives of this study were to determine the perceived role of food on GI symptoms and to determine the impact of food-induced symptoms on quality of life (QOL) in children with functional GI disorders. Between August and November 2010, 25 children ages 11 to 17 years old with functional GI disorders and a parent completed a food symptom association questionnaire and validated questionnaires assessing FGID symptoms and QOL. In addition, children completed a 24-hour food recall, participated in focus groups to identify problematic foods and any coping strategies, and discussed how their QOL was affected. Statistical analyses were conducted using χ2, t test, Mann-Whitney U test, Wilcoxon signed rank, and Spearman's ρ. Children identified a median of 11 (range=2 to 25) foods as exacerbating a GI symptom, with the most commonly identified foods being spicy foods, cow's milk, and pizza. Several coping strategies were identified, including consuming smaller portions, modifying foods, and avoiding a median of 8 (range=1 to 20) foods. Children reported that food-induced symptoms interfered with school performance, sports, and social activities. Although the parent's assessment of their child's QOL negatively correlated with the number of perceived symptom-inducing foods in their child, this relationship was not found in the children. Findings suggest that specific foods are perceived to exacerbate GI symptoms in children with functional GI disorders. In addition, despite use of several coping strategies, food-induced symptoms can adversely impact children's QOL in several important areas.     

Food allergy challenges: guidelines and implications

Double-blind placebo-controlled food challenges were used to determine the presence or absence of food hypersensitivity in 120 children with atopic dermatitis. Foods to be challenged were selected on the basis of history, allergy skin tests, nutritional significance, and patient desires. Dehydrated foods were hidden in capsules or juice and administered twice a day. Antigens were obtained commercially or prepared through a process of freeze-drying and subsequent pulverization. Cutaneous, gastrointestinal, nasal, and/or respiratory symptoms occurred following 133 challenges. Although patients exhibited multiple positive skin tests to foods, 86% experienced a positive response on blinded challenge to only one or two foods. Double-blind placebo-controlled food challenges accurately diagnose food hypersensitivity and minimize the number of foods eliminated from allergy avoidance diets. A new method of elimination diet management and education is based on the identification of "key words" on food labels. Instructional diet sheets were developed to teach this concept, which was found to promote greater confidence, compliance, and creativity in diet planning.     

Crohn's disease affects diet and growth in children

Background: Thirteen (eight girls, five boys) patients, aged 9.8–15.4 years, and 13 controls matched for age and sex were studied to identify foods that might aggravate the symptoms of children with Crohn's disease, to examine the adequacy of nutrient intake and to assess nutritional status.
Methods: The link between symptoms and food intake was determined by 48-h dietary recall on two separate occasions and by a dietary questionnaire. Nutritional status was assessed using growth charts and biochemical values.
Results: Patients with Crohn's disease identified several foods that aggravate symptoms. The intakes of bread, cereals and fat were greater in patients than in controls. The mean relative (% energy) intake of protein was lower, but the mean absolute intake of carbohydrates was higher in patients than in controls. The intakes of vitamin D, calcium, iron and zinc by the patients were below the respective recommended dietary allowances (RDAs). Nutritional status was good in the majority of the patients. However, the mean height-for-age was lower in the patients than in the controls, and 38% of the patients had serum albumin concentrations below the reference value.
Conclusions: Symptoms and foods that aggravate symptoms may restrict diet and thus decrease nutrient intake. The diet of children with Crohn's disease may contain insufficient amounts of nutrients. In some children, Crohn's disease markedly retards growth. These results substantiate the need for coordinated dietetic follow-up.     

Management of patients with food intolerance in irritable bowel syndrome: the development and use of an exclusion diet

Food intolerance is an important cause of abdominal symptoms. As no objective tests are available to identify the foods concerned, diets are essential for the management of these patients. The fewer foods allowed in the diet, the greater is die chance of success. Our original studies of 182 patients between 1979 and 1982, using a diet of lamb, rice and pears, had resulted in a 67% success rate. The foods most commonly involved were wheat (60%), cows' milk (44%) and corn (44%). A less restrictive exclusion diet was developed from the results of this work, avoiding all those foods to which 20% or more of the patients had been intolerant. Of 253 patients (79%), 200 were able to complete 2 weeks on this diet and 100 (50%) were successful in controlling their symptoms. The exclusion diet was modified in the light of this experience and in a subsequent study of 129 patients, 96 (75%) were able to comply for 2 weeks, but only 39 (41%) improved on the basic diet. However, examination of the food diaries of these patients enabled the identification of less frequent food intolerances in 21 (22%) giving an overall success rate of 60 (63%). In this way, equally good results can be obtained using a nutritionally adequate exclusion diet and avoiding the difficulties of following a more rigorous elimination regime.     

Ernährungstherapie bei Nahrungsmittelallergien

A therapeutic diet is only indicated if the diagnosis of food allergy is certain. In the case of an unproven suspicion everything should be done to confirm or disprove the diagnosis by diagnostic measures (patient history, diet history, food and symptom protocol etc.). In the case of proven food allergy there are different aims of nutritional therapy. Most importantly the patient should learn how to identify his eliciting agent in pre-packed and non-prepacked food and how to avoid it. The elimination diet should take into account the individual condition of the patient. In particular, if basic foods have to be eliminated from the diet, safe alternatives have to be determined to maintain a nutritionally balanced diet and to maintain a high quality of life. To ensure the nutritional adequacy of the diet, micro- and macronutrient intake should be analysed and improved, if necessary. For pollen-associated food allergy and certain chronic conditions it might be necessary to be aware of possible triggering factors as well as potential cross-reactions. Moreover, individual tolerance should be maintained during elimination diets and not jeopardized by voluntary and unnecessary self-denial of certain foods.     

Artificial food dyes and attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in children. Symptoms of ADHD include hyperactivity, low frustration tolerance, impulsivity, and inattention. While the biological pathways leading to ADHD are not clearly delineated, a number of genetic and environmental risk factors for the disorder are recognized. In the early 1970s, research conducted by Dr. Benjamin Feingold found that when hyperactive children were given a diet free of artificial food additives and dyes, symptoms of hyperactivity were reduced. While some clinical studies supported these findings, more rigorous empirical studies conducted over the next 20 years were less positive. As a result, research on the role of food additives in contributing to ADHD waned. In recent years, however, interest in this area has revived. In response to more recent research and public petitions, in December 2009 the British government requested that food manufacturers remove most artificial food dyes from their products. While these strictures could have positive effects on behavior, the removal of food dyes is not a panacea for ADHD, which is a multifaceted disorder with both biological and environmental underpinnings.     

Linear and nonlinear programming to optimize the nutrient density of a population's diet: an example based on diets of preschool children in rural Malawi

BACKGROUND: Food consumption surveys are often used to detect inadequate nutrient intakes but not to determine whether inadequate nutrient intakes are due to suboptimal use of locally available foods or to insufficient availability of nutrient-dense foods. OBJECTIVES: The objectives were to describe the use of linear programming as a method to design nutrient-adequate diets of optimal nutrient density and to identify the most stringent constraints in nutritional recommendations and food consumption patterns in a population's diet. DESIGN: This analysis was conducted with the use of food consumption data collected during 2 seasons from rural Malawian children aged 3-6 y. Linear programming was used to select diets based on local foods that satisfied a set of nutritional constraints while minimizing the total energy content of the diet. Additional constraints on daily intakes of foods and food groups were also introduced to ensure that the diets were compatible with local food patterns. The strength of the constraints was assessed by analyzing nonlinear programming sensitivity. RESULTS: In the harvest season, it was possible to satisfy nutritional recommendations with little departure from the local diet. In the nonharvest season, nutritional adequacy was impaired by the low availability of riboflavin- and zinc-rich animal or vegetable foods and by the high phytate content of other foods. CONCLUSIONS: This analysis suggests that nutrition education may help improve the diets of children in the harvest season, whereas changes in the range of available foods might be needed in the nonharvest season. Linear and nonlinear programming can be used to formulate recommendations with the use of data from local food consumption surveys.     

Dietary Patterns in Children with Attention Deficit/Hyperactivity Disorder (ADHD)

The role of diet in the behavior of children has been controversial, but the association of several nutritional factors with childhood behavioral disorders has been continually suggested. We conducted a case-control study to identify dietary patterns associated with attention deficit hyperactivity disorder (ADHD). The study included 192 elementary school students aged seven to 12 years. Three non-consecutive 24-h recall (HR) interviews were employed to assess dietary intake, and 32 predefined food groups were considered in a principal components analysis (PCA). PCA identified four major dietary patterns: the “traditional” pattern, the “seaweed-egg” pattern, the “traditional-healthy” pattern, and the “snack” pattern. The traditional-healthy pattern is characterized by a diet low in fat and high in carbohydrates as well as high intakes of fatty acids and minerals. The multivariate-adjusted odds ratio (OR) of ADHD for the highest tertile of the traditional-healthy pattern in comparison with the lowest tertile was 0.31 (95% CI: 0.12–0.79). The score of the snack pattern was positively associated with the risk of ADHD, but a significant association was observed only in the second tertile. A significant association between ADHD and the dietary pattern score was not found for the other two dietary patterns. In conclusion, the traditional-healthy dietary pattern was associated with lower odds having ADHD.     

“More Than Buying Extra Fruits and Veggies,Please Hide the Fats and Sugars”: Children’s Diet Latent Profiles and Family-Related Factors

Promoting children’s healthy diets is a key public health priority. Family can play a relevant role in children’s eating patterns. The goals of the current research were to identify different latent diet profiles in children based on their food consumption and to assess the relationship between profiles and family-related factors. A total of 678 school-aged children from the fifth and sixth grades participated. The study design was cross-sectional and questionnaire based. Research assessed healthy (fruit and vegetables) and unhealthy (fast food, sugar-sweetened beverages, and candies) food consumption and family-related factors. A latent profile analysis and multivariate data analysis were developed. Four diet profiles were identified: Combined Diet, Mainly Healthy Diet, Mainly Unhealthy Diet, and Very Unhealthy Diet. Nearly half of the children (45.22%) showed a Combined Diet profile, meaning that they reported eating nearly the same amount of healthy and unhealthy types of foods. Associations between the diet profiles, family income, and food availability were found. For example, the Mainly Healthy Diet profile was statistically associated with a higher family income and less access to unhealthy foods. The present study reinforces the idea that profiling diets can allow for a tailored healthy eating intervention model according to the specific needs of each diet profile.     

Multivariate analysis of diet among three-year-old children and associations with socio-demographic characteristics. The Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC) Study Team

STUDY OBJECTIVE: The study of the whole diet in combination rather than the consumption of individual food items or the intake of specific nutrients could be enlightening. This has been previously performed using principal components analysis (PCA) on adult diets but not on those of children. DESIGN: The frequency of consumption of a range of food items was recorded for 10,139 3-y-old children by their mothers using self-completion postal questionnaires. These children form part of the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC). METHODS: PCA was performed to identify individual dietary types which were then related to various socio-economic and demographic characteristics. RESULTS: Four distinct dietary components were obtained explaining 23.5% of the total variation in the sample, and the socio-demographic characteristics of the sample were related to them. The first represented a diet based on convenience foods and was associated with younger, less educated mothers and the presence of older siblings. The second was associated with a high consumption of foods currently considered to be healthy and was particularly related to vegetarian mothers and higher education levels. The third component described the established British 'meat and two veg' diet and was associated with girls and children with no older siblings, while the fourth had high loadings for snack and finger foods and was related to socially advantaged conditions and the presence of older siblings. CONCLUSIONS: Identifiable groups of mothers were associated with feeding their child each of the four dietary types, supporting the hypothesis that social, demographic and lifestyle factors relating to the mother have an influence on the early eating patterns of children. This analysis will form a basis for the future study of various childhood outcomes including growth, health and development. SPONSORSHIP: University of Bristol European Journal of Clinical Nutrition (2000) 54, 73-80     

Traditional Individual and Environmental Determinants of Healthy Eating in Vihiga County,Western Kenya

Traditional ethnic groups in Kenya are unlikely to eat a healthy and diversified diet due to many individual and environmental factors, which may result in poor health status. Therefore, the determinants of eating behavior need to be identified prior to any public health action. For this study, focus group discussions (15 in total) in a double-layer design were conducted, comprising adult men and women from 5 villages of Vihiga County. Questions explored knowledge; barriers and cues to action toward eating a healthy diet containing a variety of foods; including indigenous food species. We found that healthy eating concepts are known; however, several taboos that restrict food consumption reduce local diet quality in terms of diversity. Nutrition education is a cue to action. We identified several individual and environmental determinants of eating behavior in the studied communities. Public health action should focus on supporting healthy eating behaviors and refining some taboos’ beliefs.     

Physical Complaints Decrease after Following a Few-Foods Diet in Children with ADHD

Attention-deficit hyperactivity disorder (ADHD) symptoms may significantly decrease after following a few-foods diet (FFD). The results of a small randomised controlled trial (RCT) showed that co-occurring physical complaints in children with ADHD decreased as well. To further investigate the effect of an FFD on physical complaints, we analysed unpublished data from previously published studies (i.e., ‘Impact of Nutrition on Children with ADHD’ [INCA], an RCT, and ‘Biomarker Research in ADHD: the Impact of Nutrition’ [BRAIN], an open-label trial). In both trials, the association between an FFD, ADHD, and 21 individual physical complaints was assessed. Children either followed a 5-week FFD (the INCA FFD group and BRAIN participants) or received healthy food advice (the INCA control group). The ADHD rating scale and a physical complaint questionnaire were filled in at the start and end of the trials. The INCA results showed, for 10 of 21 complaints, a clinically relevant reduction in the FFD group compared to the control group. The open-label BRAIN results confirmed the outcomes of the FFD group. No association was detected between the decrease in physical complaints and the decrease in ADHD symptoms. The results point toward an association between the FFD and a decrease in thermoregulation problems, gastrointestinal complaints, eczema, and sleep problems.     

Immunologically mediated contact urticaria caused by foods in young children with constitutional eczema]

Fifty-two children with atopic dermatitis were investigated with the mixed-food radio-allergosorbent test (RAST) and the skin provocation test 'Skin Application Food Test' (SAFT). The mixed-food RAST is a commercially available test with multiple allergens on one disk. The disk contains 6 common food allergens: cow's milk, egg, peanut, soy, codfish and wheat. The SAFT is a system with which foods are applied to the skin in the state in which they are consumed. This test system is routinely used in our subdivision of Paediatric Dermatology in Sophia Children's Hospital. In some children, atopic dermatitis grew worse after a positive SAFT reaction. In 50% of the 38 children with food allergy a correlation was found between exacerbation/induction of atopic dermatitis and consumption or direct skin contact of foods to which the child was allergic. Due to direct skin contact of foods, atopic dermatitis can grow worse with sudden attacks of pruritus, especially on the hands and in the face. The SAFT imitates the naturally occurring symptoms, is child friendly and easy to perform. The mixed-food RAST can be used as a screening test to identify the children with atopic dermatitis and an atopic immune response to foods, so possibly food allergy. Further investigations of the sensitivity of the target organ (in atopic dermatitis: the skin) and the usefulness of the SAFT are then indicated.     

Key foods in Sweden: Identifying high priority foods for future food composition analysis

High quality food composition data are essential in cutting-edge research, for example on diet and health, so regular updates and improvements of food composition data are necessary. However, food analyses are expensive, and for optimal use of resources, tools to aid prioritisation are required. This study sought to identify key foods in the Swedish diet, in order to set priorities for future nutrient analyses of foods. A slightly modified version of the key foods approach developed by the Nutrient Data Laboratory in the United States was used. Existing nutrient values were combined with food consumption data from the national dietary survey Riksmaten Adults 2010–11. Key foods were identified group-wise using key nutrients for each food group. Of the 1894 foods included in the survey, 320 (17%) were identified as key foods contributing 75% of intake of the key nutrients in each food group. These key foods will be prioritised in future food composition analyses.     

Food Sources of Macronutrients in the Diets of Fifth Grade Children on Guam

PURPOSE. This study was conducted to develop food lists consisting of the top food sources for energy (calories), protein, carbohydrate, fat, cholesterol, and dietary fiber for children in the fifth grade on Guam. METHODS. The food intake of fifth-grade children on Guam, ages 9 through 13, was collected using a one-day food record and computer-analyzed for nutrient content. The 1,006 individual food items from the food records were condensed into 194 food aggregations. Food lists including the 50 major contributors of each nutrient were formulated. Each list represents at least 82% of the total intake per macronutrient. PRINCIPAL FINDINGS. Many of the major contributors of energy, total fat, cholesterol, and protein in the diet of children on Guam are meat dishes, fried chicken, canned corned beef, and whole milk. Rice is consumed frequently and is an important contributor of energy, protien, carbohydrate, and fiber. Sweet beverages provide much of the dietary energy and carbohydrate. Potato and tortilla chips, although low in fiber, are eaten frequently and become major contributors of fiber. CONCLUSIONS. The foods that contribute to macronutrient intake in these fifth graders include many that are high in fat, processed, have low nutrient density, and are unlike foods traditionally consumed on Guam. RELEVANCE. These lists identify foods currently being consumed by children on Guam. These lists can be used to develop culturally specific nutrition education and dietary assessment instruments for children on Guam in an effort to reduce chronic disease risk factors and encourage positive health behaviors in children. KEY WORDS. Macronutrients, Energy, Food, Diet, Children, Guam, Chamorro     

Cows’ Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35–52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows’ milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows’ milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0–17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows’ milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.