CHAPTER 5
Feingold and FAILSAFE Diets; Low Salicylate and Low Phenol Diets
WHAT ARE SALICYLATES? WHAT ARE PHENOLS?
Salicylates are chemicals found in plants and in many fruits and vegetables. They are also in medications including aspirin and other pain-relieving medications as well as in many common health and beauty products. Salicylates are thought to protect plants from insect damage and disease. Phenols are naturally occurring chemicals that are high in a number of foods such as apples, bananas, berries, grapes, tomatoes, cocoa, soy, and dairy products. Salicylates are a type of phenol; however, not all phenols are salicylates. (A more complete description follows.)
There are numerous foods that contain salicylates or phenols. However, defining the salicylate or phenol content of foods is not as easy as determining their presence or absence as can be done with the “all or none” foods such as gluten, milk/casein, soy, eggs, corn, and nuts. There are numerous factors that can affect the salicylate or phenol content of a food. These include:
• The season of the year or the location in which the food is grown
• Growth method
• Use of pesticides, preservatives, or additives
• The part of the food/plant tested
• Freshness or degree of ripeness
• Peeled vs. unpeeled
• Preparation and cooking method (e.g., raw vs. cooked)
• Differences based on the brand/variety of the food
In addition, the level in a particular plant may change. For example, according to the Feingold website, an organic fruit that has been attacked by pests will make more salicylates than other fruits. According to one research article, there can even be differences in the concentration of phenolic compounds in fruit grown on the same tree or on different sides of the same piece of fruit, based on exposure to sunlight.
To add to the confusion, there are multiple different ways in which levels of salicylates and phenols are reported. This makes review of the literature challenging and leads to resources and websites that offer differing lists. One reporting measurement is the amount of salicylates per 100 grams of the food/product. For salicylates, greater than 1 mg/100 grams is considered high. People do not generally eat food by the gram. Another reporting measurement is the amount per “typical serving size” of a food. While you might eat several hundred grams of fruit in a typical serving size, you may consume far less than 100 grams of other salicylate-containing foods such as spices. Herbs and spices are not consumed in 100-gram amounts; however, their salicylate content is highly concentrated and extremely high even in very small amounts. Clinically, this is the reason we observe salicylate reactions to many of the spices.
Yet another confounding factor is the “bioavailability” of the salicylate or phenol based on the type of food. Bioavailability means how available that chemical is to the body based on metabolism by intestinal bacteria, absorption from the intestine, chemical structure, etc. Because of this factor, some foods that are high in salicylates or phenols on a list may not cause as many symptoms as might be expected because the chemical is not well absorbed. For example, pears are listed as a higher phenol containing food than tomatoes. However, in our clinical experience, tomatoes commonly cause phenol symptoms whereas pears are generally very well tolerated.
As authors, we reviewed numerous articles and listings of salicylate/phenol content and created our own grids and lists based on our best synthesis of currently available materials. The reader may find other listings or resources that differ somewhat from ours, because of the factors cited above. We have tried to include our best guidance, based on our decades of clinical experience, regarding which foods are commonly most problematic and which foods are generally tolerated, to help guide the reader in initiating these diets.
What Is the Feingold Diet?
The Feingold Diet was established by Benjamin Feingold, MD, a pediatrician and allergist who felt that hyperactivity was triggered in some children by an immunological reaction (not allergic reaction) to certain synthetic additives (such as colors, flavors, and preservatives) and foods containing salicylates. The Feingold Diet removes foods containing certain harmful ingredients or additives. In the Feingold Program, nonfood items containing problematic ingredients are also removed. Removal of these foods and items is a diagnostic trial to determine which are causing problematic behaviors. Stage I of the Feingold Program involves eliminating synthetic dyes, artificial flavors and specific preservatives entirely. It also involves removing naturally occurring salicylates from the diet until a favorable response is seen. Once improvement is seen, Stage II involves reintroducing some of the fruits and vegetables, with assessment of tolerance. Other ingredients and products can then be added back individually to help determine which are causing problems. Fortunately, most individuals are not reactive to all of the listed ingredients or additives. The success of the diet depends on the degree of a person’s sensitivity to salicylates and the amount of exposure.
WHAT ARE THE CULPRIT FOODS OR INGREDIENTS?
Foods and additives that are eliminated include:
• Foods and products containing salicylates (see list below)
• Artificial food coloring (petrochemical dyes)
• Artificial flavors and fragrances
• Three preservatives (petrochemical preservatives: BHA, BHT, TBHQ)
• Artificial sweeteners (aspartame, acesulfame-K, cyclamates, saccharine, and sucralose)
What Foods Contain Salicylates?
There are numerous foods that contain salicylates. Foods are categorized as being either high, medium, or low salicylate foods. The amount of salicylates in a food can vary for numerous reasons, as described above. The chart shown here lists high, medium and low salicylate foods based on our best synthesis of available data.
What Are Problematic Food Colorings, Flavors, or Fragrances?
ARTIFICIAL FOOD COLORINGS: Nearly all of the dyes in foods, medicines, toothpaste, beverages, vitamins, cosmetics, etc. are synthetic. Red 40 and Yellow 5 are the most used food dyes in the United States.
ARTIFICIAL SWEETENERS: Aspartame, acesulfame-K, cyclamates, saccharine, and sucralose.
ARTIFICIAL FLAVORS OR FRAGRANCES: For a complete list, see the Feingold Association’s website, www.feingold.org
HOW DO I DO THE DIET?
For specific details on how to do the diet as recommended by the Feingold Association, see its website at www.feingold.org. With a membership, you can obtain a handbook, listings of potentially problematic and more allowable foods, and more specific guidance on doing this diet. A more general approach would be to first remove high salicylate foods that are common in your child’s diet for at least 4 weeks. Also remove food dyes and artificial flavorings. If there is no obvious improvement or insufficient improvement, then consider removing medium and/or lower salicylate foods for an additional 2–4 weeks. After observing the response, you can reintroduce foods one at a time every 3–5 days and watch for negative reactions. This will help isolate/identify those foods that are causing problems.
WHAT SYMPTOMS MAY BE HELPED BY THE FEINGOLD DIET?
In our clinical experience, the most commonly reported symptoms that seem to be triggered by these foods are hyperactivity and behavioral outbursts. However, any negative behavior could be potentially triggered by these foods or chemicals including irritability, oppositional or defiant behaviors, temper tantrums, inattention, anxiety, mood swings, or learning problems. Some people with salicylate sensitivity also have physical symptoms such as nasal congestion, asthma-like symptoms, itching, skin rashes, hives, stomachaches, or headaches.
WHEN SHOULD I CONSIDER A TRIAL OF THE FEINGOLD DIET FOR MY CHILD?
We would suggest considering a trial of this diet if:
You have observed reactions to foods containing certain dyes, additives, or flavorings (e.g., food dyes, MSG).
Your child has symptoms often seen with sensitivity to phenols (see the Phenol section of this chapter), but the response to removal of phenols alone was ineffective or only partially effective.
You have tried medications and the response was insufficient.
You have tried the gluten-free casein-free diet and the response was insufficient.
What Is the FAILSAFE Diet?
The FAILSAFE diet was created by allergists at the Royal Prince Alfred Hospital in Australia. They felt that glutamates and biogenic amines found in foods had similar effects on the body as salicylates. This diet is similar to the Feingold diet, but with removal of additional potentially aggravating chemicals. FAILSAFE stands for Free of Additives, Low in Salicylates, Amines and Flavor Enhancers. The diet excludes:
Approximately 50 artificial food additives: colors (such as food dyes), flavors, preservatives, and antioxidants (sulfites, nitrates, benzoates, sorbates, parabens)
Salicylates and polyphenols found in a wide range of fruits and vegetables
Phenolic free-glutamates (MSG) and other food source glutamates
Neurotransmitters in food: amines (histamine, serotonin, dopamine, phenylethylamine, tyramine, and others) found in aged proteins and fermented foods (cheese, chocolate, game, hung meat)
Aromatic (strong smelling and tasting) chemicals: Such as those found in perfumes, cleaning products, commercial cosmetics, and scented and colored toiletries, especially mint and menthol products
Some pharmaceutical drugs including aspirin, NSAIDs and other COX II inhibitors (e.g., Ibuprofen and the methyl-salicylates found in decongestants and anti-inflammatory creams)
According to the website, www.failsafediet.com, this diet eliminates virtually all processed foods, many fruits and vegetables (with a small number of exceptions), aged or preserved proteins like ham, well-hung beef, game, and cheese. It also prohibits use of commercially manufactured cosmetics and perfumes (particularly mint and menthol products) that contain large amounts of salicylates and other chemicals that cross-react in salicylate-sensitive individuals such as benzoates. It also eliminates aspirin and COX II inhibitors; acetaminophen is allowed. The diet is composed mainly of very fresh (non- vacuum packed or hung) meat, chicken and white fish, eggs, fresh dairy products (if tolerated), many but not all grains (if tolerated), peeled potatoes, beans, peeled pears, and a number of green vegetables including cabbage and Brussels sprouts. Strong flavors, additives, many exotic fruits and vegetables, and spices are not allowed.
This diet is clearly very restrictive and would be very challenging to maintain for even the most motivated of families. In our opinion, this diet should be reserved for children who have significant behavioral issues not improved by other traditional or dietary/biomedical interventions. It should be done as a time-limited trial with the goal of identifying specific problematic foods.
WHAT IS A LOW PHENOL DIET?
Phenols are widely available, naturally occurring compounds found in high concentrations in a number of foods. Phenols have antioxidant qualities and protective functions, so some are beneficial and good to consume for most individuals. Foods that are particularly high in phenols include apples, bananas, berries, red grapes, tomatoes, oranges, cocoa, soy and dairy products. Fruits that are lower in phenols and better tolerated include pears, mangoes, and melons. Some individuals, particularly those on the autism spectrum, have difficulty handling phenols.
Phenols are cleared from the body by an enzyme in the liver, phenol sulfotransferase (PST). Enzymes in the body serve a number of functions, including converting one form of a chemical into another so it can be used in subsequent reactions or eliminated from the body. Enzymes require certain “cofactors” or nutrients to help them work most efficiently. Even if an enzyme is present in sufficient amounts, if the cofactor is deficient, the enzyme will be more sluggish. A helpful analogy is to consider that enzyme pathways are like roads or highways. If an enzyme does not have sufficient cofactors, there will be a traffic jam, much like a highway going from four lanes to two lanes. You can still get where you are going, just not very efficiently. If the nutrient the enzyme needs is given, the road construction blockade is lifted and the traffic jam resolves. The PST enzyme requires sulfate. Some individuals, particularly those with autism, do not have enough sulfate. The enzyme then does not work efficiently and phenols can become a problem. If sulfate is given, phenols will be cleared more efficiently. A good source of sulfate is Epsom salts, whose chemical name is magnesium sulfate. Epsom salts can be added to bath water. There are also several commercially available magnesium sulfate creams that allow sulfate to be absorbed through the skin; these have the advantage that they can be applied several times per day to provide more consistent sulfate to the enzyme than a once-daily bath. (See the authors’ supplement book for more details.)
SALICYLATE CONTENT OF FOODS
CATEGORY |
HIGH-SALICYLATE FOODS |
MEDIUM-SALICYLATE FOODS |
LOW-SALICYLATE FOODS |
Fruit |
Apples (Granny Smith), apricots, avocado, berries, cantaloupe, cherries (sweet), coconut, cranberries, currants, dates, fig (dried), grapes (fresh or red), grapefruit, guava, mandarins, nectarines, oranges, peaches, pineapples (fresh), plums (canned), prunes, raisins, rockmelon, sultana, tangerines, tangelo |
Apples (Jonathan), grapefruit juice, kiwi, loquat, lychee, nectarine (fresh), pear (with peel), plum (fresh), watermelon |
Apples (golden & red delicious), bananas, cherries (sour, canned), fig, grapes (green), lemon (fresh), mango, passion fruit, pawpaw, pear (peeled), persimmon, pineapple juice, pomegranate, rhubarb, tamarillo |
Vegetables |
Alfalfa, artichoke, broad beans, broccoli, capsicum (green), champignon (canned), chicory, chili, corn (creamed), courgette, cucumber, eggplant, endive, fava beans, gherkin, mushroom (canned), okra, olives (green), pepper (sweet), radish, spinach (fresh), squash, sweet potato (white), tomato (paste, sauce & canned), water chestnut, watercress |
Asparagus (canned), beetroot (canned), bok choy, choy sum, corn (canned), lettuce (other than iceberg), maize, olives (black), parsley, parsnip, potato (red), pumpkin, snow peas (& sprouts), sweet potato (yellow) rhubarb |
Asparagus (fresh), bamboo shoots, beans, bean sprouts, beetroot (fresh), Brussels sprouts, cabbage, carrot (fresh), cauliflower, celery, chives, choko, corn (fresh), eschallots, French beans, horseradish. leeks, lentils, lettuce (iceberg), mung bean (& sprouts), mushroom (fresh), onion, peas (fresh or dried), pimento (canned), potato (peeled or unpeeled white), pumpkin, spinach (frozen), soybeans, swedes, tomato (fresh), turnip |
Nuts and Seeds |
Almonds, macadamia, peanuts, pine nuts, pistachio |
Brazil nuts, coconut (desiccated), pumpkin seeds, walnuts |
Cashews, hazelnuts, pecans, peanut butter, poppy seeds, sesame seeds, sunflower seeds |
Spices |
Allspice, anise seed, basil, cayenne, celery, cinnamon, cloves, cumin, curry powder, dill, fenugreek, five spice, garam masala, ginger, mace, mint, mixed herbs, mustard, oregano, paprika (hot or sweet), pepper, rosemary, sage, tarragon, turmeric, thyme, Vegemite, vinegars (red and white wine, cider, and others) |
Cinnamon, cumin, oregano, sage |
Chives, coriander, salt |
Other |
Clover honey, molasses |
Honey (except for clover honey) |
All grains (except maize), cocoa, dairy products, meat, seafood, brown and white sugars, golden and maple syrups, molasses |
The PST enzyme system is an important part of the body’s detoxification pathways, which remove toxins from the body that come from internal sources (metabolism) and from external sources (environmental chemicals, certain additives in foods). When the enzyme is not functioning well, phenols and salicylates from foods, toxins and chemicals that are high in these substances are not cleared well and the metabolite traffic backs up; this can cause a variety of behavioral symptoms. Remember, the phenols are beneficial to the system; it is the PST deficiency or decreased function that is the problem. Artificial coloring and flavorings are the most significant load on the PST system, but high-salicylate foods are significant too. This can be confusing because while salicylates are a type of phenol, not all phenols are salicylates. Environmental chemicals and toxins, especially petroleum byproducts, also weigh heavily on the PST system. Again, supporting the enzyme allows it to clear all of these chemicals more efficiently.
Symptoms and physical signs that suggest your child may have a phenol sensitivity include:
Intermittent flushed red cheeks or ears that occur without obvious explanation
Hyperactivity
Unexplained silliness or laughing
Disrupted sleep, especially unusual laughter when waking during the night
Anger and/or aggression
Sweating at night
Large variations in functioning ability
Regression in behavior after eating high phenol foods
For initial implementation of a low phenol diet, we recommend removing the following items, which we have found to be the biggest culprits:
Artificial colorings, flavorings, and preservatives
Fruits: apples, bananas, berries, oranges, red grapes, raisins, and tomatoes
Chocolate and cocoa
Milk products (animal source)
Soy
Vanillin
The best-tolerated fruits to use as substitutes include pears, mangoes, and melons.
There are three main categories of phenols: salicylates, amines, and glutamates.
Salicylates: Includes aspirin and other salicylate medications, and phenolic salicylate foods
Amines: Dietary amines come from protein breakdown in foods. They increase in meat, fish, and cheese as they age and in fruits as they ripen (bananas, tomatoes).Vasoactive amines are neurotransmitters present in foods: dopamine, histamine, phenylethylamine, serotonin, tyramine. Foods high in these are well-known triggers of migraines.
Glutamate: Glutamate is an excitatory neurotransmitter, affecting normal and abnormal brain function. Free (unbound) glutamate is problematic for many. Excesses of glutamate can cause migraines and contribute to hyperactivity.
If removing the most common phenol culprits from the diet has not resulted in improvement, consider avoiding more phenolic foods: more phenolic salicylates, phenolic amines, and/or phenolic glutamates.
NOTE: Different apples and grapes have different levels of salicylates. However, all apples are high in phenols so all types should be removed when doing a low phenol diet trial. While red grapes are higher in phenols than green grapes, both types showed be removed during a low phenol diet trial. Cocoa powder contains negligible amounts of salicylates but should be avoided on a low phenol diet.
HIGH-PHENOL FOODS TO AVOID FOR A LOW-PHENOL DIET
*Note that bolded items are the most significant
PHENOL SALICYLATE SOURCES |
PHENOL AMINE SOURCES |
PHENOL FREE-GLUTAMATE SOURCES |
Artificial: food coloring, flavoring, and preservatives Apples, apple juice Berries: blackberry, black currant, blueberry, chokeberry, elderberry, raspberry, strawberry Bananas Beans: black, white Celery seeds Cherries Chocolate (dark), cocoa Cloves Globe artichoke heads Honey Grapes (especially red) Milk products (animal source) Nuts: Almonds, hazelnuts, pecans, walnuts Olives Oranges, orange juice Plums Raisins Seasonings: cloves, dried peppermint, spice mixes, star anise Soy Spinach Teas: black, green Tomatoes Vanillin |
Aged meats Almond flour Avocado (ripened) Banana (ripened) Berries Bouillon Broad beans (Fava) Canned fish Cheeses (mature) Cherries Chocolate Citrus fruits Coconut flour and milk Deli meats Eggplant Fake crab meat/surimi Fruit flavored yogurt Grapes Hummus Kiwi fruit Mushrooms Nuts: most nuts and seeds Oils: almond, avocado, coconut, extra virgin olive oil, sesame, walnut Olives Passion fruit Pickled vegetables Pineapples Plums Sauerkraut Soy Spinach Tomatoes Vegetable juice, stocks, soups |
Monosodium glutamate (MSG) Sources Autolyzed yeast, yeast extract Bouillon Calcium caseinate Carrageenan Citric acid Corn starch Corn syrup Flavoring Gelatin Hydrolyzed items Maltodextrin Milk powder Modified food starch Monopotassium glutamate Pectin Soy protein Soy sauce Textured protein Whey protein isolate Natural Sources of Free-Glutamate Aged, matured preserved foods Bone broths Bouillon Broad bean/fava Broccoli Casein Deli meats Dried fruits Fish sauce Gluten Grape juice Malted barley Mushrooms Peas Soy protein Soy sauce Spinach Tomatoes (ripe) |
How Do I Know Which of These Diets to Do and in What Order?
We suggest first trying a low phenol diet, as it is the least restrictive of the above diets. If phenols are an issue for your child, the response to removal (or providing adequate sulfate) is often rapid and dramatic. If the improvements are negligible with removal of phenols or not sufficient, then removal of other high salicylate foods could be considered as a next, time-limited step. If you want to go further, removal of foods on the medium- or low-salicylate list or on the FAILSAFE list could also be considered. Once items have been removed, individual foods or products can be introduced individually, with at least 3–5 days in-between introduction of each, to try to identify which agents or foods are problematic. In regard to phenol sensitivity, if a child reacts to one high phenol food, he is likely to react to others; in this situation, most high phenol foods need to be removed, until or unless the enzyme that helps clear phenols can be adequately supported (e.g., by sulfate and other supportive nutrients). Fortunately, children who react to salicylates do not seem to react to all of them, so it is more common to be able to identify specific significant problematic foods or chemicals (such as MSG, for example).
What Else Can Be Done?
The PST enzyme is supported by a number of nutrients, most importantly sulfate, B6, and magnesium. Because B6 is interdependent with other B vitamins, a phenol-free multivitamin mineral supplement that provides B vitamins as well as other supportive nutrients can also be helpful. As previously noted, Epsom salt baths and/or magnesium sulfate creams are also good sources of sulfate to support the enzyme. Other sulfur-bearing nutrients can also be helpful. For those with more significant phenol problems, there may be benefit from phenol-targeting enzymes, available in supplement specialty stores and sites. Supporting enzyme functions can be complex; therefore, in order to design the most appropriate regimen for your child, we recommend a consultation with a health care practitioner who has expertise in these treatments.
FEINGOLD/LOW SALICYLATE DIET |
Chapter 5 |
What Are Salicylates and Where Are They Found?
Avoid:
Why Is the Diet Needed?
Symptoms the Diet May Help:
Diet Includes:
Resources:
|
|
FAILSAFE/LOW SALICYLATE DIET |
Chapter 5 |
What is FAILSAFE?
Avoid:
Why Is the Diet Needed?
Symptoms the Diet May Help:
Diet Includes:
Resources:
|
|
LOW PHENOL DIET |
Chapter 5 |
What Are Phenols?
Avoid: Strictness is based on results. Some individuals must be rigid in adherence
Why Is the Diet Needed?
Symptoms the Diet May Help:
|
|
Diet Includes:
Organic is important. Foods, low in phenol and high in sulfur: meat, poultry, seafood, eggs; garlic, onion shallots, leeks, broccoli, and cabbage
Other foods: Grains (not rye and wheat); Beans/legumes (not black, white, soy); Fruit: pears, mango, melons; Vegetables: alfalfa, bean sprouts, Brussels sprouts, celery, chard, rhubarb, snow peas
Nuts: all except almonds, hazelnuts, pecans, walnuts
Spices: chives, cinnamon, curry, dill, fennel, ginger, mustard, oregano, pepper, rosemary, sage, tarragon, thyme, turmeric
Resources:
Enzyme Stuff: http://www.enzymestuff.com/epsomsalts.htm
Dana’s View from the Inside: www.danasview.net/phenol.htm
My Child Will Thrive: www.mychildwillthrive.com/wp-content/uploads/Low-Phenol-Resource-V2-Final.pdf
Cooking to Heal and Nourishing Hope for Autism by Julie Matthews
Cure Your Child with Food by Kelly Dorfman
“Ethan continues to improve. In the past week he has started to ask questions, which is the next step to being able to hold a conversation. I never thought I would be happy to hear ‘why?’ and ‘why not?’”
—Bea Wolman, mother of four-year-old Ethan