Nutritional Considerationsin

Autism Spectrum DisordersAnne Roland Lee, MSEd, RD

NutritionistCeliac Disease CenterColumbia University

Common Gastrointestinal Issues

• Leaky Gut

• Maldigestion

• Malabsorption

• Bacterial overgrowth

• Gastrointestinal symptoms

Potential Nutritional Deficiencies

• Protein

• Vitamins:– C, E, B- complex, B 6

• Minerals:– Calcium, magnesium, chromium

• Calories

• Fiber

Common Nutrition Profile

• Lower serum magnesium

• Lower B6 level

• Elevated copper levels

• B 12 deficiency

Nutritional Treatments

• 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

Beyond the Diet

• 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

Gluten Content of Foods

• 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

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

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

Health Concerns

• Low nutrient density of commonly consumed gluten-free products

• Potential side effects of usual gluten free diet:– Overweight– Constipation– Elevated lipids

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)

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

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

Comparison of gluten-free and wheat based products

• Gluten-free products• Increased:

– Fat– Calories

• Decreased:– Fiber– B- Complex vitamins– Minerals

Comparison of Regular & GF Pretzels

Calorie Protein Fat Iron Calcium0

20

40

60

80

100

120

140

160

Regular Pretzels

GF Pretzels

Comparison of Pastas

Protein Fat Fiber Thiamin Riboflavin Niacin Iron Calcium0

2

4

6

8

10

12

Regular Spaghetti

GF Bean

GF Corn

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

Comparison of Starches

0

2

4

6

8

10

12

Protein Fiber Thiamin Riboflavin Niacin Iron

Rice, White

Millet

Millet, Puffed

Quinoa

Potato, Baked

Potato, Boiled

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

Comparison of Diet Totals

0

100

200

300

400

500

600

700

Calories Protein Fiber Thiamin Riboflavin Niacin Folate mcg Iron Calcium

Standard

Alternative

Grain Comparisons

Grain Protein Fiber Thiamin Niacin Folate Iron Calcium

Rice*

(Enriched) Millet Teff Buckwheat Quinoa Sorghum flour Chickpea flour

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

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

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

Table 4

National Comparison of Regular and Gluten-Free Products

  Regular Gluten-free P value

Bread (price/oz) 0.15 0.23 0.00

Cereal (price/oz) 0.32 0.35 0.27

Waffles (price/oz) 0.27 0.35 0.05

Crackers (price/oz) 0.36 0.78 0.00

Cookies (price/oz) 0.34 0.51 0.00

Pretzels (price/oz) 0.34 0.77 0.01

Pasta (price/oz) 0.11 0.24 0.00

Pizza (price/oz) 0.33 0.55 0.00

Macaroni and Cheese (price/oz) 0.25 0.34 0.01

Cake (price/oz) 0.31 0.86 0.12

Significant at a 5% confidence interval excluding cereal & cake

Bread Cereal Waffles Crackers Cookies Pretzels Pasta Pizza Macaroni & Cheese

Cake

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Pri

ce p

er o

un

ce

Regular

Gluten-Free

Comparison of Regular and Gluten-Free Products: Values are mean of price per ounce of all venues in all regions

Figure 3

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

Casein Content of Foods

• 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

• Hidden sources– Packaged mixes

– Sauces

– Baked products

– Snacks and snack bar****CAREFUL LABEL READING****

GFCF Diet

• Nutritional deficiencies– Vitamins

• B –complex,

– Minerals• Calcium, Iron

– Fiber– Potentially macronutrients also

• Protein, calories

Nutritional Approach to GFCF

• 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

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

Nutritional Approach to ASD

• 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

Beyond the Diet

• Other considerations;– Texture– Aroma– Color– Shape– Wet vs. dry foods– Temperature

Diet Recommendations

• 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

• 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

• 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

• 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

• 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

• Texture– Meats:

• Cook tender• Ground meat in sauces

– Vegetables• Pureed in sauces• raw

– Fruits• Raw• Cooked then dried off

Diet Recommendations

• 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

http://lambcutlet.org/albums/Queensland_Art_Gallery/I_decided_to_have_a_fruit_salad_with_yoghurt_at_the_Watermill_Cafe_inside_Queensland_Art_Gallery.sized.jpg

Supplementation

• 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

Take home message

• 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