Saturday, July 26, 2008

Much Better MSN Feingold Article

After a highly credulous Feingold article last summer, MSN manages to get someone who knows what they are talking about. Our favorite online news-source medical expert….Dr. Rob does a reasonable job providing factual information about food sensitivities and ADHD.

For the casual reader, the Feingold diet was an elimination diet that gained some popularity in the 70s and 80s as a treatment for hyperactivity and ADHD. There was some early research that indicated it might be useful, but by the mid 90s it was clear that the larger, better controlled studies were not showing an effect.

As always none of this deterred the believers, as the comments from last year show. But that is another story for another day. Thank you MSN!

7 Comments:

Anonymous María Luján said...

Hi IV
I consider many of the comments form several posters in your blog last year very insightful and informative-such as pD. I disagree with the assignation of believers to their attitude.
New findings on diet and AHDH
Eur Child Adolesc Psychiatry. 2008 Apr 21.
A randomised controlled trial into the effects of food on ADHD.Pelsser LM, Frankena K, Toorman J, Savelkoul HF, Pereira RR, Buitelaar JK.
ADHD Research Centre, Liviuslaan 49, 5624 JE, Eindhoven, The Netherlands,

The aim of this study is to assess the efficacy of a restricted elimination diet in reducing symptoms in an unselected group of children with Attention deficit/hyperactivity disorder (ADHD). Dietary studies have already shown evidence of efficacy in selected subgroups. Twenty-seven children (mean age 6.2) who all met the DSM-IV criteria for ADHD, were assigned randomly to either an intervention group (15/27) or a waiting-list control group (12/27). Primary endpoint was the clinical response, i.e. a decrease in the symptom scores by 50% or more, at week 9 based on parent and teacher ratings on the abbreviated ten-item Conners Scale and the ADHD-DSM-IV Rating Scale. The intention-to-treat analysis showed that the number of clinical responders in the intervention group was significantly larger than that in the control group [parent ratings 11/15 (73%) versus 0/12 (0%); teacher ratings, 7/10 (70%) versus 0/7 (0%)]. The Number of ADHD criteria on the ADHD Rating Scale showed an effect size of 2.1 (cohen's d) and a scale reduction of 69.4%. Comorbid symptoms of oppositional defiant disorder also showed a significantly greater decrease in the intervention group than it did in the control group (cohens's d 1.1, scale reduction 45.3%). A strictly supervised elimination diet may be a valuable instrument in testing young children with ADHD on whether dietary factors may contribute to the manifestation of the disorder and may have a beneficial effect on the children's behaviour.

Fatty acid status and behavioural symptoms of Attention Deficit Hyperactivity Disorder in adolescents: A case-control study

Nutritional therapies for mental disorders
I think that more research like this would clarify more and more the role of nutrition in ADHD subgrops.

7:53 AM  
Blogger Interverbal said...

Hi Maria,

PD's comments were reasonable. I was primarily referring to someone else.

I was ignorant of the Pelsser study. However, I notice that there is a lack of objective evaluation. This has been a problem with other studies in the elimination diet world too.

I do not consider this study to be of good quality because of its lack of objectivity.

8:41 AM  
Blogger Joseph said...

Plus the Pelsser et al. study, while randomized, appears to lack blinding from evaluators. I realize blinding from participants would be difficult here. Those in the waiting list would know they were not being treated.

9:51 AM  
Anonymous María Luján said...

Hi
You said
lack of objective evaluation.
Related to whom?
Objective evaluation is extremely difficult to know as such. As many parents and reserachers know, children tend to be very different in the presence of strangers evaluating them than in the case of people they trust and know.
How do you think an objective evaluation could be then done? there are plenty of reports about how children misbehave in doctors/ and researchers environments and they are very different in environments that consider their interests.This is not a confounder considered in many studies with supposed objective evaluation.
Even more, teachers could be considered a kind of the objective evaluators- because they are not the parents. Before and after the begining of the study, the environment is known to the children, such as the evaluator.
In my country doctors request the child´s teacher a report to know about the ADHD of the child and they consider their reports to analyze the medication or not.
Truly the blind aspect in dietary aspects is almost not possible to achieve. Parents know what their children eat in these studies.

10:19 AM  
Blogger Interverbal said...

Hi Maria,

“Related to whom?’

Parents and teachers.

“Objective evaluation is extremely difficult to know as such. As many parents and reserachers know, children tend to be very different in the presence of strangers evaluating them than in the case of people they trust and know.”

Which is why there could have been a pre-treatment condition to both monitor for abnormalities in the data and to acclimate the students. There is no reason the Hawthorne or “observers” effect should be present in the treatment phase and absent in the baseline if the same evaluators are used.

“Even more, teachers could be considered a kind of the objective evaluators- because they are not the parents.”

You are assuming the teachers have no bias… that is never a good assumption in research. The teachers were still informed about the study, and from what I can tell there was no significant effort to make them naïve as to which condition a child was in. They were not blinded.

Moreover my all time favorite study involves teachers being a movie of a typically developing but active male child. They were told he was ADHD and the teachers quickly began to label of his unmistakably ADHD traits.

Truly the blind aspect in dietary aspects is almost not possible to achieve. Parents know what their children eat in these studies.

What about the Elder (2006) GF/CF study where the parents didn’t know?

1:01 PM  
Anonymous María Luján said...

You are assuming the teachers have no bias… that is never a good assumption in research.

Well, you are assuming the researchers have no bias- even unconscious. I wish the same study to be done with doctors/researchers in the topic of ADHD and you will see.

About Elder et al, we have discussed in disagreement about in somewhere else.
Quote from the discussion
My opinion
You know, I also think that the study is flawed in the sense that concludes that the diet is not useful but for me BECAUSE all the other medical concomitant problems are not addressed here, not because the diet- depending on the individual. In this sense I agree with you. Only with studies considering complete approaches to several detected problems for example:
1-Gut problems
2-Allergies
3-Essential metals defficiencies (Zn) and fatty acids, aminoacids and vitamin defficiencies
4-Digestive conditions (lack of enzymes such as lactase, disaccharidases, dipeptidylpeptidases, amylases, proteases,e tc)
5-Other bacterial and fungal problems going on
I consider the studies are going to show a trend.

In this kind of studies, during a lot of time, natural maturation and placebo effects must be considered confounders to analyze properly.

The problem is that there are not enough studies -considering the concomitant medical problems- to know the role of the nutritional external support- but there are a few.

Even if the goal was not the elimination of peptides, the GFCF diet would only avoid an stressor, but would not solve any concomitant medical condition. When a diet is considered, such as in this case, a concerned and commited doctor talks you about nutritional support in terms of vitamins and Ca supplementation to begin with. Considering also the Gut health, and looking at this, at least Gut/GI issues are tested and , if detected, treated concomitantly (fungus, bacteria anaerobic, h. pylori) and the gut supported properly. I would not expect big changes from the diet only in 6 weeks ( especially fi you have Fe/Mg/Ca/Zn problems PLUS aminoacids problems PLUS folic acid problems PLUS lactic acidosis problems, for example)- and the concomitant problems remain untreated.

You answered me that this was out of the scope of the article
My comment that time
Perhaps it is not the goal, but affects the overal situation of the analysis of the effect of the GFCF diet and therefore it is important.
I wonder about the effect of the GFCF diet if concomitantly all the issues I mentioned would have been considered.
The only thing that this small study present is that the diet ALONE produces no improvement in autistic children that are not celiac- if a small study is considered without further testing.BTW, this fact has been recognized anecdotically long time ago. Children who react very possitively to the diet have in general specific kind of reactions to gluten(/casein) IgE or non-IgE mediated that need careful and specific testing to be diagnosed.
and more on Elder et al
Therefore the problem is how is done ( the diet) and with what support. But how is done depends many times of the support the family finds in the peditrician or other doctors. And you must go from one to the other to get the indications of the studies you consider necessary to complete the details of the clinical presentation ( yes, the experience is internationally similar). Many times the concerns with bread and milk are totally dismissed- and BOTH are also many times very much related to the well being of the child and related to underlying problems. Therefore the problem is partially how is the GFCF diet done by the families and ALSO the lack of support many times families have in their peditrician/other to get the GFCF diet properly checked and completed in the clinical analysis.Therefore PART of the problem is the lack of knowledge of doctors about the complete presentation of GI issues related to gluten/casein- and relation to malabsorption and/or immune abnormal status, being the child autistic or not. BUT if the child is autistic, all is the autism for the mainstreamed doctor and this is EXTREMELY worrisome because leaves the situation such as it is.

Elder et al. is of very limited value and has the confounders of the lack of the address of the potential digestive or other problems- not tested, neither known or reported in the study.

3:45 PM  
Blogger Interverbal said...

Hi Maria,

“Well, you are assuming the researchers have no bias- even unconscious. I wish the same study to be done with doctors/researchers in the topic of ADHD and you will see.”

No, I already agree with you that many researchers come to table with biases. Of course there are many ways to control for this problem, double-blinding, inter-observer agreement, etc.

You and I have explored the Elder study in some detail before now. I am aware of your criticisms of it. But please note that I do not cite Elder et al. (2006) as a perfect study. I cite it only as a study that proved you can do a diet based behavioral study without violating the blinding of the parents.

8:34 PM  

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