NUTN 507: Seminar in Childhood Nutrition

Graduate Programs in Human Nutrition

May 19
th
, 2014
4:00-5:00 PM
Presented by: Jeremy D. ONeal

An Alternative, Non-Pharmacological Approach to Reducing ADHD-Related Hyperactivity in Children

Learning Objectives: After attending this presentation, members of the audience will be able to:
1. Report behavioral characteristics of attention deficit hyperactivity disorder (ADHD) and its
related societal challenges
2. Hypothesize the connection between dietary sodium benzoate intake and increased
hyperactivity in children with ADHD
3. Compare and contrast pharmacological interventions to non-pharmacological, dietary
modifications for reducing ADHD-related hyperactivity

Attention deficit hyperactivity disorder (ADHD) is diagnosed in 11% of 4-17 year old children but can
affect individuals of all ages.
1,2
The Centers for Disease Control estimate ADHD-related healthcare costs
were between $36-$52 billion in 2005.
3
Characterized by hyperactivity, impulsiveness, inability to control
behavior, and/or inattention,
2
ADHD can lead to failure in education, mental illness, delinquency, and other
interpersonal problems.
4
A physician diagnoses ADHD based on a childs expressed behaviors with
confirmation from either a family member or teacher that these behaviors are common.
5
Additionally, for
ADHD to be diagnosed, hyperactive, impulsive, and/or inattentive behaviors must not be within the normal
range for an individuals age and development.
5

Current pharmacological treatments that alleviate the symptoms of ADHD include stimulants to
reduce hyperactivity, non-stimulants to reduce impulsivity, and psychotherapy to improve social interactions.
The National Institutes of Mental Health support pharmacological and psychotherapeutic interventions as an
effective means to treat the multiple ADHD symptoms
5
as no cures for ADHD exist.
6
Pharmacological
interventions have been associated with reduced height gains for children, elevated systolic and diastolic
blood pressures, reduced appetites, altered sleep cycles, headaches, and dizziness.
7

Non-pharmacological interventions include dietary modifications that either eliminates artificial food
preservatives and colorants or supplements with fish oil in order significantly reduce hyperactivity in ADHD-
affected children.
6
Elimination of all artificial preservatives and colorants, including sodium benzoate, has
resulted in a significant reduction of many ADHD related symptoms, especially hyperactivity.
6,8-10
Sodium
benzoate, commonly used as a food and cosmetic preservative, has not been studied singly, but is often a
component of test drinks and other food items shown to increase hyperactivity in children.
10
A community-
based, randomized, double-blinded, placebo-controlled study demonstrated increased hyperactivity in eight
and nine year old children after consuming a solution of sodium benzoate and either allura red or sunset
yellow artificial food colorants.
11
Sodium benzoate has also been shown in rodent models to stunt growth and
reduce appetite.
12
The Food and Drug Association (FDA) generally recognizes as safe (GRAS) food items
with 0.1% final weight of sodium benzoate,
13
though many beverages exceed this percentage.
14

Sodium benzoate has been shown to induce anxiety and impair motor skills within a rodent
population.
15
One explanation for this effect may be an increased serum ammonia level as sodium benzoate
has been linked to ammonia toxicity within both human and rodent models.
16,17
Elevated serum ammonia
levels can lead to inflammation of neurons.
18
Neuroinflammation has been linked to hyperactivity and
reducing this inflammation significantly reduces a childs number of hyperactive episodes.
19
Additionally,
sodium benzoate contains no essential nutrients and is concentrated in soft drinks and other beverages.
14

Therefore, omitting this dietary additive poses no harmful risk. A registered dietitian can counsel parents with
children affected by ADHD to restrict this preservative in their diet in order to reduce overall hyperactivity,
while understanding each families specific barriers.
References
1. Polanczyk G, Rohde LA. Epidemiology of attention-deficit/hyperactivity disorder across the lifespan. Curr Opin Psychiatry
2007;20:386-92.
2. Akinbami LJ, Liu X, Pastor PN, Reuben CA. Attention Deficit Hyperactivity Disorder among Children Aged 5-17 Years in the United
States, 1998-2009. NCHS Data Brief. Number 70. Centers for Disease Control and Prevention 2011.
3. Bloom B, Cohen RA. Summary health statistics for U.S. children: National Health Interview Survey, 2006. Vital Health Stat 10
2007;(234):1-79.
4. Nijmeijer JS, Minderaa RB, Buitelaar JK, Mulligan A, Hartman CA, Hoekstra PJ. Attention-deficit/hyperactivity disorder and social
dysfunctioning. Clin Psychol Rev 2008;28:692-708.
5. Ferguson JH. National Institutes of Health Consensus Development Conference Statement: Diagnosis and Treatment of Attention-
Deficit/Hyperactivity Disorder (ADHD). J Am Acad Child Adolesc Psychiatry 2000;39:182-93.
6. Sonuga-Barke EJ, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, Stevenson J, Danckaerts M, Van der Oord S, Dpfner M.
Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and
psychological treatments. Am J Psychiatry 2013;170:275-89.
7. Rapport MD, Moffitt C. Attention deficit/hyperactivity disorder and methylphenidate: a review of height/weight, cardiovascular, and
somatic complaint side effects. Clin Psychol Rev 2002;22:1107-31.
8. Pelsser LM, Frankena K, Toorman J, Savelkoul HF, Pereira RR, Buitelaar JK. A randomised controlled trial into the effects of food on
ADHD. Eur Child Adolesc Psychiatry 2009;18:12-9.
9. Bateman B, Warner JO, Hutchinson E, Dean T, Rowlandson P, Gant C, Grundy J, Fitzgerald C, Stevenson J. 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. Arch Dis Child 2004;89:506-11.
10. Millichap JG, Yee MM. The diet factor in attention-deficit/hyperactivity disorder. Pediatrics 2012;129:330-7.
11. McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, Kitchin E, Lok K, Porteous L, Prince E. 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.
The Lancet 2007;370:1560-7.
12. Nair B. Final report on the safety assessment of Benzyl Alcohol, Benzoic Acid, and Sodium Benzoate. Int J Toxicol 2001;20 Suppl
3:23-50.
13. Food and Drug Administration. CFR - Code of Federal Regulations Title 21. Internet:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=184.1733 (accessed 4/30/2014 2014).
14. Aprea E, Biasioli F, Carlin S, Mrk TD, Gasperi F. Monitoring benzene formation from benzoate in model systems by proton transfer
reaction-mass spectrometry. International journal of mass spectrometry 2008;275:117-21.
15. Noorafshan A, Erfanizadeh M, Karbalay-Doust S. Sodium benzoate, a food preservative, induces anxiety and motor impairment in
rats. Neurosciences (Riyadh) 2014;19:24-8.
16. O'Connor J, Ribelles M, Grisolia S. Potentiation of hyperammonemia by sodium benzoate in animals. A note of caution. Eur J
Pediatr 1982;138:186-7.
17. O'Connor J, Costell M, Grisolia S. The potentiation of ammonia toxicity by sodium benzoate is prevented by L-carnitine. Biochem
Biophys Res Commun 1987;145:817-24.
18. Rodrigo R, Cauli O, GomezPinedo U, Agusti A, HernandezRabaza V, GarciaVerdugo J, Felipo V. Hyperammonemia induces
neuroinflammation that contributes to cognitive impairment in rats with hepatic encephalopathy. Gastroenterology 2010;139:675-84.
19. Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder
symptomatology: systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry
2011;50:991-1000.