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NEWS: Rory Watson European agency rejects links between hyperactivity and food additives BMJ 2008; 336: 687-a [Full text]

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'Lack of evidence' does not mean no evidence

Om Prakash   (26 March 2008)

Atrificial Food Colours, Preservatives and Hyperactivity: Evidence is accumulating

Muzafar Hawramy, London, HA8 7BJ   (28 March 2008)

Other problems with food preservatives and added colours.

Marise A McQueen   (3 April 2008)

'Lack of evidence' does not mean no evidence 26 March 2008
Om Prakash, Assistant Professor of Psychiatry Geriatric Clinic & Services, Department of Psychiatry, NIMHANS, Bangalore, INDIA Send response to journal: Re: 'Lack of evidence' does not mean no evidence	It seems that the European Food Safety Authority has taken the decision in favor of food additives in the absence of studies. However, the decision can be justified but the authority cannot ignore the harmful effects of food additives. The absence of evidence does not mean no side effects. More studies are needed to give more insights links between hyperactivity and food additives. The clinicians must take utmost care while telling their clients about this decision. Competing interests: None declared
Atrificial Food Colours, Preservatives and Hyperactivity: Evidence is accumulating 28 March 2008
Muzafar Hawramy, Psychiatrist Barnet, Enfield, & Haringey Mental Health NHS Trust, London, HA8 7BJ Send response to journal: Re: Atrificial Food Colours, Preservatives and Hyperactivity: Evidence is accumulating	Having cited both the Randomised Controled Trail addressing the effect of arificial colours and preservatives on the ( hyperactivity ) on children and the trails evaluation by the Europian Food Safety Authority(EFSA) published on 14.03.2008 , I thought also about the tremendous suffering of children and parents affected by the Hyperactivity. Many parents describe how elemination of artifitial colours and preservatives in the diet of their children has reduced their children's hyperactivity, impulsivity, and inattentiveness. This means using the common sense and face validity ( Do not give your child what makes him hyperactive) has already helped many children to have better life, education, and healthy future. Now, in the era of evidence based medicine we have also accumilating scientefic evidence. A metaanalysis in 2004 concluded that childrens behaviour significantly improved when artificial colours eleminated from the diet( Schab & Trinh. 2004). A randomised double blind placebo controled trail( McCann et al. 2007) that took a sample from a full range of socioeconomic background in United Kingdom provides further evidence. The trial ensured the randomization, precise intervention, and blinding during the assessment. It shows that children who used the artificial colors scored higher on Global Hyperactivity Aggregate ( measuring hyperactivity based on observed behaviour) compared to children who had placebo. The effect size is significant(0.20), 95% CI 0.01-0.39, P= 0.044). The trial recruited children from both sexes. Taking into account that hyperactivity is more common in boys, the effect size might have been even greater, had the study recruited boys only. The Europian Food Safety Authority (EFSA) suggests that the study provides a limited evidence. It also critisizes the small effect size. For this a pannel set-up by the EFSA concluded that the study could not be used as a basis for altering the preservatives often present in sweats and soft drinks and ( Acceptable Daily Intake) of artificial colours. Having taken in to account the impact of the hyperactivity on many domains of childs life; safety, education, satisfactory social relationships, self-esteem, ....etc, even a small effect size could be important. It is recognised that in United Kingdom most children with marked hyperactive behaviour are not identified, referred, or treated( Sami Timimi/ Eric Taylor). For this the problem might be bigger than we currently think. For this, any significant preventative measure should be taken seriously. As the EFSA suggests, not all additives used might be responsible for the hyperactivity. For this it might be good that future trials compare single additives or preservatives with pacebo. This might lead to altering of most hazardous preservatives or artificial colours to the least hazardous. Qualitative studies addressing how parents describe changes seen in their children following exclusion of artificial colours and preservatives in their diet will add more to the currently accumulating evidence. It seems that the scientific evidence is currently significant but we need more to persuade other who are sceptical. I think it is the matter of time until we can say: Now we have enough scientific proof. References: 1.Sami Timimi/ Eric Taylor ADHD is best understood as a cultural construct- British Journal of Psychiatry 2004, 184, 8-9 2. Donna MCCann et al Food additives and hyperactivity behaviour in 3-year old and 8/9 year old children in the community: A randomised double -blind-placebo controlled trail, Lancet 2007; 370: 1560-67 3. http://www.efsa.europa.eu 4. Schab, D.W. & Trinh, N.H. Do artifitial colours promote hyperactivity syndromes. A metaanalysis of double- blind-placebo- controlled trials- Journal of behavioural and developmental paediatrics 2004, 25(6) 423-434 Competing interests: None declared
Other problems with food preservatives and added colours. 3 April 2008
Marise A McQueen, Staff Grade, Anaphylaxis Clinic Western Infirmary, Glasgow, G11 6NT Send response to journal: Re: Other problems with food preservatives and added colours.	Those of us who work in the few allergy clinics in the UK will be aware of a possible link between added preservatives and colours in foods and the development of a variety of 'pseudo-allergic' symptoms and signs. These can be early - within an hour, or late - often manifesting as waking up with the symptom. It is also known that these agents can exacerbate Chronic Urticaria in some patients. There may be a similarity in mechanism to that proposed as the reason for Aspirin (and food salicylate content) exacerbations of Urticaria/ angioedema/asthma/anaphylaxis. I beleive that this is an additional reason for caution with these aromatic carbohydron chemicals. 1. Urinary Metabolites of histamine and leukotrienes before and after placebo-controlled challenge with ASA and food additives in chronic urticaria patients. Di Lorenzo, G et al, Allergy, vol 57(12), Dec 2002, p 1180-1186. 2. Increased Leukotriene production by food additives in patients with atopic dermatitis and proven food intollerance. Worm,m et al, Clinical & Experimental Allergy, Vol31(2), Feb 2001, p 265-273. Competing interests: None declared