Nutritional Considerations in Autism Spectrum Disorders

1. Nutritional Considerationsin Autism Spectrum Disorders Anne Roland Lee, MSEd, RD Nutritionist Celiac Disease Center Columbia University

2. Leaky Gut Maldigestion Malabsorption Bacterial overgrowth Gastrointestinal symptoms Common Gastrointestinal Issues

3. Protein Vitamins: C, E, B- complex, B 6 Minerals: Calcium, magnesium, chromium Calories Fiber Potential Nutritional Deficiencies

4. Lower serum magnesium Lower B6 level Elevated copper levels B 12 deficiency Common Nutrition Profile

5. Gluten Free- Casein Free diet Many families have positive results Restrictive diet – socially isolating Glycemic Indexing Measure the response of individual foods on blood sugar Affect diminished in mixed meals Nutritional Treatments

6. GFCF diet has great success Univ of Rochester Double blind study on 30 children on gfcf diet Initial results: Took twice as long to adapt to diet regime Picky eaters – ate more variety ***surprised parents  Caloric intake met growth needs Adequate intakes Increased levels of vit C, Mg Beyond the Diet

7. Gluten Commonly found in Wheat, Rye and Barley Breads, pastas, cereals, processed foods Oats safe grain but caution with cross contamination Hidden sources – potential problem Thickener for soups, gravies, sauces Art and craft supplies Ubiquitous ingredient Gluten Content of Foods

9. Nutritional Deficiencies of Gluten-free diet • Studies • Hallert • Population 30 adults • On diet for 8 to 12 years • Reviewed both lab data and 4 day food diary • Results • Increased body weight • Males increased 9.8 kg (from 70.4 to 79.2 kg) • Females increased 9.9 kg ( from 62.1 to 71.0 kg) • 56% had signs of nutritional deficiency • No evidence of iron deficiency

10. Nutritional Deficiencies • Hallert, continued • Other findings • Increased homocysteine level – poor vitamin status • Biopsy proven remission – not malabsorption • Number of bread servings comparable to controls • Folate intake from bread products was lower • Increased intake of greens and root vegetables • Decreased intake of fruits

11. Health Concerns • Low nutrient density of commonly consumed gluten-free products • Potential side effects of usual gluten free diet: • Overweight • Constipation • Elevated lipids

12. Health Concerns • Dickey’s research • Population: 371 diagnosed over ten year period • Compared BMI at diagnosis and at two year follow up • Results: • 4% underweight (BMI<18.5) • 57% normal BMI (18.5-24.9) • 39% overweight (BMI >25) • 13% of these were obese (BMI>30)

13. Health Concerns • Dickey, continued • Two year follow up: • Mean BMI rose from 24.4 to 25.9 • Weight gain in 81% • No change in 4% • Weight loss in 15% • 82% of the initial overweight patients gained more • Conclusions: • Usual gluten free diet prescription needs to be modified or at least individualized

14. Research conclusions • Gluten-free diet • Potentially deficient in: • calcium, fiber, iron and B Complex vitamins • Alternatives • Increase use of greens, fruits and folate rich vegetables – Hallert • Increase total number of grain servings per day, especially whole grain - Thompson

15. Comparison of gluten-free and wheat based products • Gluten-free products • Increased: • Fat • Calories • Decreased: • Fiber • B- Complex vitamins • Minerals

18. Comparison of starches • Standard gluten free diet relies on corn, rice and potato as the main starches • Rice is fortified and therefore provides a good source of folate • Lacking in fiber, other B complex vitamins, and minerals • Many “alternative grains” fill these nutritional deficits

20. Dietary Comparisons • Comparing the standard gluten free diet to one with “alternate grains” interesting results • Changing only the source of grain • increase the fiber, thiamin, folate, calcium, and protein • decrease the fat content of the diet

22. Grain Comparisons

23. Sensory benefits • Taste, texture, satiety • Millet – mild flavor, fluffy texture • Hot side dish • Quinoa – takes on flavor or other ingredients, similar to cous cous • Hot side dish, cold salad, hot cereal • Buckwheat – nutty flavor, barley like • Hot side dish, cereals, soups, baking • Teff – full nutty flavor, denser texture • Hot side dish, cereal

24. Sensory Benefits • Flours; • Not as brittle or dry as the rice flours, do not need as much sweetening or fat • Chickpea • 1: 1 ratio, no distinct flavor, light texture • Teff • Denser, needs to be lightened, nutty flavor • Sorghum • Denser, needs to be lightened, stronger flavor

25. Economic benefits • Cost comparison between gluten-free and regular products • Gluten-free products double the price of their wheat based counterparts • Availability varies both geographically and by shopping venue

26. Table 4 Significant at a 5% confidence interval excluding cereal & cake

27. Regular Gluten-Free 1.00 0.90 0.80 0.70 0.60 0.50 Price per ounce 0.40 0.30 0.20 0.10 0.00 Waffles Cookies Bread Cereal Pretzels Pasta Pizza Crackers Cake Macaroni & Cheese Figure 3 Comparison of Regular and Gluten-Free Products: Values are mean of price per ounce of all venues in all regions

28. Recommendations • Cereals: oats, buckwheat, amaranth and quinoa • Side dishes: quinoa, millet, buckwheat • Pasta: use navy bean or enriched corn based • Breads: use high fiber, one with additional seeds and/or nuts • Flours: use chickpea, teff • mix nut meals and bean flours

29. Casein Protein found in milk Yogurt, puddings, cheese, ice cream Added to breads, crackers, cookies Labels Listed as milk, dry milk powder, sodium caseinate, hydrolyzed protein Casein Content of Foods

30. Hidden sources Packaged mixes Sauces Baked products Snacks and snack bar ****CAREFUL LABEL READING**** Casein content of foods

31. Nutritional deficiencies Vitamins B –complex, Minerals Calcium, Iron Fiber Potentially macronutrients also Protein, calories GFCF Diet

32. Careful label reading Many non gluten or casein based items could be potentially irritating Many hidden sources of gluten and casein Many sugar substitutes Many gums Many artificial colors, flavors etc Nutritional Approach to GFCF

33. Practical approach • Add foods slowly • Fiber issue • Experiment with combinations • Use oats instead of breadcrumbs • Used crushed nuts for pie crust and breading on meats • Need to become familiar with the grains • Casein substitutes

34. Minimize use of processed foods The more processed the fewer nutrients Higher fat and sugar content Reserve for quick meal or treat Hectic days deserve a balance If a favorite combine with a new food Nutritional Approach to ASD

35. Other considerations; Texture Aroma Color Shape Wet vs. dry foods Temperature Beyond the Diet

36. Avoid congestion on the plate or table Too many foods at once may be overwhelming Avoid mixing too many colors or textures Can become too loud Diet Recommendations

39. Back to basics First take a breath Then remember: Slowly, slowly, slowly Work with in accepted forms Try and try again Breath often, try to see the humor Diet Recommendations

40. Aroma Cold is best Seasonings Vanilla, cinnamon Yes even on protein based foods Try different spices – avoid common garlic etc Fruits in cooking to mask aroma Applesauce on pork, chicken Orange with beef Diet Recommendations

41. Wet vs. Dry Wet Add fruit sauces Add pureed vegetables to gravy Dry Use pureed vegetables or fruits in baking Use alternate flours in baking cookies etc Temperature Go with the flow Children do not have same rules as adults Diet Recommendations

42. Basics Protein each meal or snack Smaller more frequent meals/snacks Grab and go Easy access Cut up fruit or vegetables while watching TV Cookies made with high protein flours as snack “Cookie bar” for breakfast Diet Recommendations

44. Texture Meats: Cook tender Ground meat in sauces Vegetables Pureed in sauces raw Fruits Raw Cooked then dried off Diet Recommendations

45. Color Look for nutritional variety within accepted colors White foods Add quinoa to white rice Chickpea flour in place of rice flour Shape Use cookie cutters Prepare foods in accepted shapes Cutting does not decrease nutritional value – may increase intake Diet Recommendations

47. Multivitamin Chewable if tolerated Liquid; add to accepted food Calcium Fortified fruit juices Chewable form Nuts Fiber Ground flax meal – add to pudding, yogurt, cereal Supplementation

48. Be a parent Let your medical team be the disciplinarian Rome was not built in a day Nutritional adequacy is measured over time Not each meal or day Enjoy the accomplishments Take home message