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Do dietary interventions improve ADHD symptoms in children?
PROBABLY NOT, based on available data. Insufficient evidence exists to suggest that dietary interventions improve the symptoms of attention deficit hyperactivity disorder (ADHD) in children (strength of recommendation: B, extrapolation from randomized controlled trials [RCTs]). Interventions that have been investigated include removal of sugar and artificial food colorings from the diet and supplementation with fatty acids.
Evidence summary
ADHD affects 7% to 8% of school-age children, and the prevalence is increasing.1 The quality of studies investigating the link between diet and ADHD is limited by small sample sizes, subjective outcome measures, and nonstandardized intervention protocols.
Elimination diets show little or no effect
Studies of elimination diets for ADHD have investigated the effects of withholding sugar and artificial food colorings (AFCs).
Sugar. A 1995 meta-analysis of 16 double-blind, randomized, placebo-controlled trials evaluated the effect of dietary sugar in the form of sucrose, glucose, and fructose on behavior or cognition of children. Outcomes included subjective measurements from teachers, parents, and researchers, as well as objective scoring of activities.
No significant differences in the summary effect size were noted for any measured variable. A weakness of the analysis was that not all of the trials studied children who had been specifically diagnosed with ADHD.2
AFCs. A 2004 meta-analysis of 15 double-blind, placebo-controlled trials (total 219 children) evaluated the effect of AFCs on hyperactivity. Outcomes were measured by behavioral rating scales that ranged from standardized forms such as the Conners Parent-Teacher Questionnaire (12 trials) to nonvalidated author-developed scales (3 trials). Analysis revealed a small summary effect size (0.283; 95% confidence interval, 0.079-0.488), and the authors concluded that AFCs do have a small effect on hyperactivity.3
A secondary analysis of children who previously showed worsening of hyperactivity with AFCs (either by parental report or in an earlier study) found a larger effect size (0.53). This finding implies that a subset of children whose parents notice an increase in hyperactivity with AFCs may benefit from exclusion. However, because the quality of the meta-analysis is limited by the heterogeneity of the studies, publication bias, unvalidated outcome measures, and variety of diagnoses in the participants, no recommendation can be made for AFC exclusion diets.3
Supplementation with fatty acids doesn’t improve symptoms
Because polyunsaturated fatty acids (PUFAs) are essential for brain development and function, a deficiency theoretically may contribute to a range of developmental disorders, including ADHD. An RCT of 63 children 6 to 12 years of age with ADHD randomly assigned the children to supplementation with the most abundant PUFA, docosahexanoic (DHA), or placebo for 4 months. Measured outcomes included objective attention evaluation by computer and written tests and standardized objective measures such as the Conners Rating Scales.4 The study found no significant improvement in any ADHD symptom.4
The findings of this trial were confirmed by another double-blinded RCT of 40 children with ADHD who were randomized to DHA or placebo. The second trial found no significant differences in ADHD symptoms after 2 months.5
Recommendations
The American Academy of Pediatrics states that there is a need for well-designed, rigorous studies of currently promoted but less well-established therapies for ADHD, such as occupational therapy, biofeedback, herbs, vitamins, and food supplements. These interventions aren’t supported by evidence-based studies at present.6
The American Academy of Child and Adolescent Psychiatry’s guidelines on managing ADHD don’t mention dietary interventions.7
Investigators from the Cincinnati Children’s Hospital report that elimination diets and food supplements have little or no quality evidence to support their effectiveness.8
1. Centers for Disease Control and Prevention. Epidemiologic issues in ADHD. Available at: www.cdc.gov/ncbddd/adhd/adhdprevalence.htm. Accessed February 2009.
2. Wolraich ML, Wilson DB, White JW. The effect of sugar on behavior or cognition in children. A meta-analysis. JAMA. 1995;274:1617-1621.
3. Schab DW, Trinh NH. Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind, placebo-controlled trials. J Dev Behav Pediatr 2004;25:423-434.
4. Voigt RG, Llorente AM, Jensen CL, et al. A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder. J Pediatr 2001;139:189-196.
5. Hirayama S, Hamazaki T, Terasawa K. Effect of docosahexaenoic acid-containing food administration on symptoms of attention-deficit/hyperactivity disorder—a placebo-controlled double-blind study. Eur J Clin Nutr 2004;58:467-473.
6. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108:1033-1044.
7. Pliszka S. AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
8. Cincinnati Children’s Hospital Medical Center. Evidence-Based Clinical Practice Guideline for Outpatient Evaluation and Management of Attention Deficit/Hyperactivity Disorder. Cincinnati: Cincinnati Children’s Hospital Medical Center; 2004. Available at: www.guideline.gov/summary/summary.aspx?doc_id=5334&nbr=003647&string=attention+AND+deficit. Accessed October 18, 2009.
PROBABLY NOT, based on available data. Insufficient evidence exists to suggest that dietary interventions improve the symptoms of attention deficit hyperactivity disorder (ADHD) in children (strength of recommendation: B, extrapolation from randomized controlled trials [RCTs]). Interventions that have been investigated include removal of sugar and artificial food colorings from the diet and supplementation with fatty acids.
Evidence summary
ADHD affects 7% to 8% of school-age children, and the prevalence is increasing.1 The quality of studies investigating the link between diet and ADHD is limited by small sample sizes, subjective outcome measures, and nonstandardized intervention protocols.
Elimination diets show little or no effect
Studies of elimination diets for ADHD have investigated the effects of withholding sugar and artificial food colorings (AFCs).
Sugar. A 1995 meta-analysis of 16 double-blind, randomized, placebo-controlled trials evaluated the effect of dietary sugar in the form of sucrose, glucose, and fructose on behavior or cognition of children. Outcomes included subjective measurements from teachers, parents, and researchers, as well as objective scoring of activities.
No significant differences in the summary effect size were noted for any measured variable. A weakness of the analysis was that not all of the trials studied children who had been specifically diagnosed with ADHD.2
AFCs. A 2004 meta-analysis of 15 double-blind, placebo-controlled trials (total 219 children) evaluated the effect of AFCs on hyperactivity. Outcomes were measured by behavioral rating scales that ranged from standardized forms such as the Conners Parent-Teacher Questionnaire (12 trials) to nonvalidated author-developed scales (3 trials). Analysis revealed a small summary effect size (0.283; 95% confidence interval, 0.079-0.488), and the authors concluded that AFCs do have a small effect on hyperactivity.3
A secondary analysis of children who previously showed worsening of hyperactivity with AFCs (either by parental report or in an earlier study) found a larger effect size (0.53). This finding implies that a subset of children whose parents notice an increase in hyperactivity with AFCs may benefit from exclusion. However, because the quality of the meta-analysis is limited by the heterogeneity of the studies, publication bias, unvalidated outcome measures, and variety of diagnoses in the participants, no recommendation can be made for AFC exclusion diets.3
Supplementation with fatty acids doesn’t improve symptoms
Because polyunsaturated fatty acids (PUFAs) are essential for brain development and function, a deficiency theoretically may contribute to a range of developmental disorders, including ADHD. An RCT of 63 children 6 to 12 years of age with ADHD randomly assigned the children to supplementation with the most abundant PUFA, docosahexanoic (DHA), or placebo for 4 months. Measured outcomes included objective attention evaluation by computer and written tests and standardized objective measures such as the Conners Rating Scales.4 The study found no significant improvement in any ADHD symptom.4
The findings of this trial were confirmed by another double-blinded RCT of 40 children with ADHD who were randomized to DHA or placebo. The second trial found no significant differences in ADHD symptoms after 2 months.5
Recommendations
The American Academy of Pediatrics states that there is a need for well-designed, rigorous studies of currently promoted but less well-established therapies for ADHD, such as occupational therapy, biofeedback, herbs, vitamins, and food supplements. These interventions aren’t supported by evidence-based studies at present.6
The American Academy of Child and Adolescent Psychiatry’s guidelines on managing ADHD don’t mention dietary interventions.7
Investigators from the Cincinnati Children’s Hospital report that elimination diets and food supplements have little or no quality evidence to support their effectiveness.8
PROBABLY NOT, based on available data. Insufficient evidence exists to suggest that dietary interventions improve the symptoms of attention deficit hyperactivity disorder (ADHD) in children (strength of recommendation: B, extrapolation from randomized controlled trials [RCTs]). Interventions that have been investigated include removal of sugar and artificial food colorings from the diet and supplementation with fatty acids.
Evidence summary
ADHD affects 7% to 8% of school-age children, and the prevalence is increasing.1 The quality of studies investigating the link between diet and ADHD is limited by small sample sizes, subjective outcome measures, and nonstandardized intervention protocols.
Elimination diets show little or no effect
Studies of elimination diets for ADHD have investigated the effects of withholding sugar and artificial food colorings (AFCs).
Sugar. A 1995 meta-analysis of 16 double-blind, randomized, placebo-controlled trials evaluated the effect of dietary sugar in the form of sucrose, glucose, and fructose on behavior or cognition of children. Outcomes included subjective measurements from teachers, parents, and researchers, as well as objective scoring of activities.
No significant differences in the summary effect size were noted for any measured variable. A weakness of the analysis was that not all of the trials studied children who had been specifically diagnosed with ADHD.2
AFCs. A 2004 meta-analysis of 15 double-blind, placebo-controlled trials (total 219 children) evaluated the effect of AFCs on hyperactivity. Outcomes were measured by behavioral rating scales that ranged from standardized forms such as the Conners Parent-Teacher Questionnaire (12 trials) to nonvalidated author-developed scales (3 trials). Analysis revealed a small summary effect size (0.283; 95% confidence interval, 0.079-0.488), and the authors concluded that AFCs do have a small effect on hyperactivity.3
A secondary analysis of children who previously showed worsening of hyperactivity with AFCs (either by parental report or in an earlier study) found a larger effect size (0.53). This finding implies that a subset of children whose parents notice an increase in hyperactivity with AFCs may benefit from exclusion. However, because the quality of the meta-analysis is limited by the heterogeneity of the studies, publication bias, unvalidated outcome measures, and variety of diagnoses in the participants, no recommendation can be made for AFC exclusion diets.3
Supplementation with fatty acids doesn’t improve symptoms
Because polyunsaturated fatty acids (PUFAs) are essential for brain development and function, a deficiency theoretically may contribute to a range of developmental disorders, including ADHD. An RCT of 63 children 6 to 12 years of age with ADHD randomly assigned the children to supplementation with the most abundant PUFA, docosahexanoic (DHA), or placebo for 4 months. Measured outcomes included objective attention evaluation by computer and written tests and standardized objective measures such as the Conners Rating Scales.4 The study found no significant improvement in any ADHD symptom.4
The findings of this trial were confirmed by another double-blinded RCT of 40 children with ADHD who were randomized to DHA or placebo. The second trial found no significant differences in ADHD symptoms after 2 months.5
Recommendations
The American Academy of Pediatrics states that there is a need for well-designed, rigorous studies of currently promoted but less well-established therapies for ADHD, such as occupational therapy, biofeedback, herbs, vitamins, and food supplements. These interventions aren’t supported by evidence-based studies at present.6
The American Academy of Child and Adolescent Psychiatry’s guidelines on managing ADHD don’t mention dietary interventions.7
Investigators from the Cincinnati Children’s Hospital report that elimination diets and food supplements have little or no quality evidence to support their effectiveness.8
1. Centers for Disease Control and Prevention. Epidemiologic issues in ADHD. Available at: www.cdc.gov/ncbddd/adhd/adhdprevalence.htm. Accessed February 2009.
2. Wolraich ML, Wilson DB, White JW. The effect of sugar on behavior or cognition in children. A meta-analysis. JAMA. 1995;274:1617-1621.
3. Schab DW, Trinh NH. Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind, placebo-controlled trials. J Dev Behav Pediatr 2004;25:423-434.
4. Voigt RG, Llorente AM, Jensen CL, et al. A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder. J Pediatr 2001;139:189-196.
5. Hirayama S, Hamazaki T, Terasawa K. Effect of docosahexaenoic acid-containing food administration on symptoms of attention-deficit/hyperactivity disorder—a placebo-controlled double-blind study. Eur J Clin Nutr 2004;58:467-473.
6. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108:1033-1044.
7. Pliszka S. AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
8. Cincinnati Children’s Hospital Medical Center. Evidence-Based Clinical Practice Guideline for Outpatient Evaluation and Management of Attention Deficit/Hyperactivity Disorder. Cincinnati: Cincinnati Children’s Hospital Medical Center; 2004. Available at: www.guideline.gov/summary/summary.aspx?doc_id=5334&nbr=003647&string=attention+AND+deficit. Accessed October 18, 2009.
1. Centers for Disease Control and Prevention. Epidemiologic issues in ADHD. Available at: www.cdc.gov/ncbddd/adhd/adhdprevalence.htm. Accessed February 2009.
2. Wolraich ML, Wilson DB, White JW. The effect of sugar on behavior or cognition in children. A meta-analysis. JAMA. 1995;274:1617-1621.
3. Schab DW, Trinh NH. Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind, placebo-controlled trials. J Dev Behav Pediatr 2004;25:423-434.
4. Voigt RG, Llorente AM, Jensen CL, et al. A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder. J Pediatr 2001;139:189-196.
5. Hirayama S, Hamazaki T, Terasawa K. Effect of docosahexaenoic acid-containing food administration on symptoms of attention-deficit/hyperactivity disorder—a placebo-controlled double-blind study. Eur J Clin Nutr 2004;58:467-473.
6. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001;108:1033-1044.
7. Pliszka S. AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007;46:894-921.
8. Cincinnati Children’s Hospital Medical Center. Evidence-Based Clinical Practice Guideline for Outpatient Evaluation and Management of Attention Deficit/Hyperactivity Disorder. Cincinnati: Cincinnati Children’s Hospital Medical Center; 2004. Available at: www.guideline.gov/summary/summary.aspx?doc_id=5334&nbr=003647&string=attention+AND+deficit. Accessed October 18, 2009.
Evidence-based answers from the Family Physicians Inquiries Network