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Diet and ADHD, Reviewing the Evidence: A Systematic Review of Meta-Analyses of Double-Blind Placebo-Controlled Trials Evaluating the Efficacy of Diet Interventions on the Behavior of Children with ADHD
Open accessAbstract
INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is a debilitating mental health problem hampering the child's development. The underlying causes include both genetic and environmental factors and may differ between individuals. The efficacy of diet treatments in ADHD was recently evaluated in three reviews, reporting divergent and confusing conclusions based on heterogeneous studies and subjects. To address this inconsistency we conducted a systematic review of meta-analyses of double-blind placebo-controlled trials evaluating the effect of diet interventions (elimination and supplementation) on ADHD. METHODS: Our literature search resulted in 14 meta-analyses, six of which confined to double-blind placebo-controlled trials applying homogeneous diet interventions, i.e. artificial food color (AFC) elimination, a few-foods diet (FFD) and poly-unsaturated fatty acid (PUFA) supplementation. Effect sizes (ES) and Confidence intervals (CI) of study outcomes were depicted in a forest plot. I2 was calculated to assess heterogeneity if necessary and additional random effects subgroup meta-regression was conducted if substantial heterogeneity was present. RESULTS: The AFC ESs were 0.44 (95% CI: 0.16-0.72, I2 = 11%) and 0.21 (95% CI: -0.02-0.43, I2 = 68%) [parent ratings], 0.08 (95% CI: -0.07-0.24, I2 = 0%) [teacher ratings] and 0.11 (95% CI: -0.13-0.34, I2 = 12%) [observer ratings]. The FFD ESs were 0.80 (95% CI: 0.41-1.19, I2 = 61%) [parent ratings] and 0.51 (95% CI: -0.02-1.04, I2 = 72%) [other ratings], while the PUFA ESs were 0.17 (95% CI: -0.03-0.38, I2 = 38%) [parent ratings], -0.05 (95% CI: -0.27-0.18, I2 = 0%) [teacher ratings] and 0.16 (95% CI: 0.01-0.31, I2 = 0%) [parent and teacher ratings]. Three meta-analyses (two FFD and one AFC) resulted in high I2 without presenting subgroup results. The FFD meta-analyses provided sufficient data to perform subgroup analyses on intervention type, resulting in a decrease of heterogeneity to 0% (diet design) and 37.8% (challenge design). CONCLUSION: Considering the small average ESs PUFA supplementation is unlikely to provide a tangible contribution to ADHD treatment, while further research is required for AFC elimination before advising this intervention as ADHD treatment. The average FFD ES is substantial, offering treatment opportunities in subgroups of children with ADHD not responding to or too young for medication. Further FFD research should focus on establishing the underlying mechanisms of food (e.g. incrimination of gut microbiota) to simplify the FFD approach in children with ADHD.
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![Fig 3 Recalculation and sub-analysis of Benton’s FFD meta-analysis [50] (3A and 3B) based on the data derived from the original articles. Forest plot of FFD effects and homogeneity statistics.](/paper-figures/f77edc504a114a7e97d5af801cd54ec0/diet-and-adhd-reviewing-the-evidence-a-systematic-review-of-meta-analyses-of-figure-3.jpg)
![Fig 4 Recalculation and sub-analysis of Sonuga-Barke et al.’s FFD meta-analysis [24] (4A and 4B) based on the data derived from the original articles. Forest plot of FFD effects and homogeneity statistics.](/paper-figures/26db05fecbdf48efb01c110c010c0958/diet-and-adhd-reviewing-the-evidence-a-systematic-review-of-meta-analyses-of-figure-4.jpg)
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“The recalculated meta-analyses found moderately large effect sizes in RCTs of the few-foods diets for any-rater measures (n=5, SMD=0.75, 95% CI: 0.31-1.19, I²=58.6%) and parent/ward observation measures (n=5, SMD=0.78, 95% CI: 0.42-1.14, I²=48.5%) of ADHD symptoms 78 .”
From A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (2020) · cites this paper as [78]
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“The results from meta-analyses of placebo-controlled trials indicated a non-significant trend towards improvement in symptoms of ADHD from AFC elimination across parent-rated measures (n=11, SMD=0.21, 95% CI: -0.02 to 0.43, I²=68%, p=0.07)”
From A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (2020) · cites this paper as [78]
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“with no effects for teacher-rated measures (n=6, SMD=0.08, 95% CI: -0.07 to 0.24, I²=0%) and observed-rated measures (n=4, SMD=0.11, 95% CI: -0.13 to 0.34, I²=12%) 78 .”
From A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (2020) · cites this paper as [78]
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Metadata
- Authors
- Pelsser, L. M., Frankena, K., Toorman, J., & Rodrigues Pereira, R.
- Affiliations
- Wageningen University & Research (NL)
- Catharina Ziekenhuis (NL)
- Corresponding author
- Pelsser, Lidy M.
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2017-01-25
- Volume
- 12
- Issue
- 1
- Pages
- e0169277
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC5266211
- OpenAlex
- W2581553063
- Cited by
- 145
- References
- 135
- Citations by year
- 2026: 11 · 2025: 8 · 2024: 16 · 2023: 14 · 2022: 20 · 2021: 26 · 2020: 20 · 2019: 13 · 2018: 11 · 2017: 4
- FWCI
- 1.99
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Socio-Environmental Systems Modeling (acceptedVersion, cc-by)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Data Archiving and Networked Services (DANS) (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
- Keywords
- attention deficit hyperactivity disorder, dietary intervention, omega-3 fatty acids, omega-6 fatty acids, n-6/n-3 ratio, child behavior, parent ratings, teacher ratings, effect size heterogeneity
- MeSH terms
- Problem Behavior, Attention Deficit Disorder with Hyperactivity, Child, Child Behavior, Double-Blind Method, Humans, Meta-Analysis as Topic, Randomized Controlled Trials as Topic, Treatment Outcome
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