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Transcript of Three Most Common Questions a WIC Nutritionist is Asked & How to Handle Them Elizabeth Strickland,...
Three Most Common Questions a WIC Nutritionist is Asked & How to Handle Them
Elizabeth Strickland, MS, RD, LDPO Box 3297 Glen Rose, TX 76043
Telephone: (830) 237-2886 Fax: (866) 855-8301Email: [email protected] Website: www.ASDpuzzle.comBOOK: EATING FOR AUTISM
Three Most Common Questions a WIC Nutritionist is Asked & How to Handle Them
AUTISMShould I put my child on the Gluten Free Casein Free Diet?
What nutritional supplements should I give my child?
My child is a picky eater how can I expand his diet?
What is Autism?Autism Spectrum Disorder299.00 Autistic Disorder299.80 Asperger’s Disorder299.80 Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)American Psychiatric Association
Autism Spectrum Disorder
ASD Puzzling childhood
disorder 1 in 88 children 1 in 54 boys Affects communication,
social interaction and behavior
Spectrum disorder
Should I put my child on the GFCF Diet?
Elimination Diets common in the autism community:
Gluten Free Casein Free Diet (GFCF)
Others: Specific Carbohydrate Diet (SCD) Gut & Psychology Syndrome Diet (GAPS) Rotation Antifungal Feingold Low Oxalate
Gluten Free Casein Free Diet
The GFCF Diet is the single most common Elimination/Challenge diet recommended for children with autism.
There is very little evidence-based
scientific research that supports or refutes claims of the GFCF Diet.
Gluten Free Casein Free Diet
Ongoing Research:
“Diet and Behavior in Young Children with Autism.”
Sponsor: National Institute of Mental Health
Clinical Trials Identifier: NCT00090428
“A Study to Assess the Role of a GFCF Diet in the
Dietary Management of Autism Associated
Gastrointestinal Disorders.”
Sponsor: Massachusetts General Hospital
Clinical Trials Identifier: NCT01116388
Website: www.clinicaltrials.gov
Gluten Free Casein Free Diet
Positive results reported by parents:Improves gastrointestinal symptomsDecreases hyperactivityIncreases focusReduces behavioral problemsImproves speech & communication skillsImproves sleep
Gluten Free Casein Free Diet
Gluten is the protein found in:
WheatBarleyRye
Common food products to avoid: Bran Couscous Cream of wheat Farina Kamut Malt Matzo/matzoh meal Oats and oatmeal Pasta Seitan Semolina Splet Tabbouleh Tritical Udon Wheat germ, flour, and starch
Gluten Free Casein Free Diet
Food additives may contain gluten: Emulsifiers Fillers Flavoring Hydrolyzed vegetable protein Texturized vegetable protein Modified food starch Seasonings Stabilizers Vegetable protein
Nonfood sources of gluten: Over the counter medications Vitamin mineral supplements Lipstick, lip gloss, & lip balms Play-Doh Glue
Gluten Free Casein Free Diet
Casein is the protein found in:
Cow’s milkCow’s milk
products
Common foods to avoid: Cow’s milk Butter Caseinates Cheese and cottage cheese Cream Curds Custard and pudding Ghee Goat’s milk Half & Half Ice Cream, Ice Milk, & Sherbet Lactoglobulin, Lactalbumin, Lactoferrin Milk chocolate Nougat Rennet Sour cream Whey Yogurt
Gluten Free Casein Free Diet
Food products and additives that may contain casein: Brown sugar flavoring Canned tuna Caramel flavoring Chocolate Commercially prepared mixes Lactic acid starter culture Margarine Packaged dinners Processed meats (hot dogs, luncheon, and sausage) Natural flavoring Nondairy creamer Salad dressings Sauces and soups Simplesse Vegetarian nondairy cheese substitutes Whipped topping
Gluten Free Casein Free Diet
Should I put my child on the GFCF Diet?
“Clinical observation and anecdotal reporting warrants a case-by-case considerationfor a GFCF Diet trial response.”
Elizabeth Strickland, MS, RD, LD
Picky Eater vs. Problem Feeder
Mealtime myths:“He’ll eat when he gets hungry enough. Kidswon’t starve themselves.”
“Don’t worry, he’ll outgrow his picky eatingstage.”
This is NOT true for most autistic childrenwho have a feeding problem as opposed to atypical developing child who is a picky eater.
Picky Eater vs. Problem Feeder
Picky Eater Decreased variety of
food (< 30 foods). Foods lost due to burn-
out regained after 2 wks. Able to tolerate new
foods on plate, touch, or taste.
Eats at least 1 food from most food textures.
Adds new foods to repertoire in 15-25 steps.
Problem Feeder Restricted range of
foods (< 20 foods). Foods lost due to burn-
out, foods not regained. “Falls apart” when
presented new foods. Refuses entire
categories of textures. Adds new foods in > 25
steps.
Kay Toomey, Ph.D.
Feeding Problem“The prevalence of problem eating
behaviors in children with autism has been
estimated to range between 46% and
89%.”
Feeding problems in children with autism spectrum disorders: a review.
Focus Autism Other Dev Disabil.
2006;21(3):153-166.
Feeding ProblemCommon Mealtime Behaviors in
Children with ASD:1. Selective food refusal2. Food neophobia (fear of trying unfamiliar foods)
3. Nonfunctional mealtime rituals
4. Tantrums
Feeding ProblemContributing Factors:1. Medical2. Psychological3. Nutritional4. Oral-Motor Dysfunction5. Sensory Processing Disorder6. Environmental7. Child 8. Parent9. Therapist10. Behavioral
Feeding Problem
Do NOT allow child to “graze” 3 meals + 3 snacks per day Limit juice, milk, beverages to appropriate amounts Avoid distractions during mealtime Practice “social modeling” Offer manageable foods Positive reinforcement Use appropriate mealtime language
Basic Mealtime Strategies
Feeding Problem
Prevent food repetition and burn-out Change one property of the same food each time
offered Expose child to a non-preferred food on a daily basis Do NOT bribe, beg, or force child to “take a bite” Limit mealtime to less than 30 minutes Keep meal & snack times a pleasant atmosphere
Basic Mealtime Strategies
Feeding Problem
Feeding Team Physician Registered Dietitian Behavioral Specialist Occupational
Therapist Speech Language
Pathologist
1. Build a multi-disciplinary Feeding Team
2. Individual team members complete an assessment
3. List of the contributing factors
4. Develop a Feeding Intervention Plan
5. Implement the feeding therapy sessions
Feeding Therapy
Feeding TherapyWhat feeding methods are NOT helpful?
1. Mere exposure to food
2. Food Deprivation
Research supports that mere exposure to food will
increase food preference among typically developing
children; however, no studies support this technique is
effective for treating children with feeding problems.
Feeding TherapyWhat feeding methods are helpful?A combination of feeding methods varying
for each child based on their individual
feeding problems.Building on preferred foodsBehavioralSensory
SOS Approach to Eating
Steps to eating:1. Tolerate2. Interact3. Smell4. Touch5. Taste6. EatingSOS Approach to EatingKay Toomey, Ph.D.Pediatric Psychologist
Feeding Problem Eating is one of the most important and
complex skills acquired in early childhood. Children with ASD typically have problems
with feeding. Feeding problems may lead to malnutrition
negatively impacting brain and body function. A multi-disciplinary approach to assessing and
treating the feeding problem is critical. The feeding treatment methods should be
individualized for each child.
What nutritional supplements should I give my child?
“There are numerous vitamins, minerals,antioxidants, amino acids, nutraceuticals andherbs believed to benefit children with ASD. These supplements are accepted and commonlyused as advanced nutritional interventions in theautism community; however, the medical community may not support their use.”
Elizabeth Strickland, MS, RD, LD
Nutritional Supplements
Lost Causes No More
Alternative Medicine
September 2004 Issue 70
Melanie Haiken
Photography by Arthur Cohen
This situation is NOT appropriate!!!
Vitamin Mineral Supplement
“Most U.S. children do not receive adequatenutrition through their diet and children with ASDhave additional nutritional concerns. Adding adaily multi vitamin and mineral supplement to theautistic child’s treatment plan is warranted.”
Elizabeth Strickland, MS, RD, LD
Vitamin Mineral Supplement
Children with ASD are at increased nutritional risk:
Sensory problemsConsume a limited variety of foodsMealtime behavior problemsElimination diets that limit certain foodsChronic gastrointestinal disorders
Vitamin Mineral Supplement
Subclinical Nutrition DeficiencyA deficiency of a particular vitamin or mineral that is not severe enough to produce a classic deficiency symptom but rather has more global, subtle effects that result in loss of optimal health and impairment of body processes.
Vitamin Mineral Supplement
Nutrient Deficiency Stages1st Preliminary → Depletion of tissue stores
2nd Biochemical → Reduced enzyme activity
3rd Physiologic/Behavior → Subclinical deficiency symptoms
4th Clinical → Symptoms worsen
5th Anatomical → Specific syndromesThe Essential Guide to Vitamins and Minerals
Elizabeth Somer, MA, RD
Vitamin Mineral Supplement
Subclinical nutrition deficiency symptoms:IrritabilityMood and behavior changesPoor concentrationDepressionAnxietySleep disturbancesLoss of appetite
Vitamin Mineral Supplement
Selection of a V/M supplement:Buy from a reputable company
Examples: Kirkman®
www.kirkmangroup.com
Village Green Apothecarywww.myvillagegreen.com
Vitamin Mineral Supplement
Selection of a V/M supplement:Quality Control Procedures
US Pharmacopeia (USP) Consumer Lab NSF International
Vitamin Mineral Supplement
Selection of a V/M supplement:Read the label
Avoid: Artificial colors and flavors Potential allergens
(wheat, milk, soy, egg, corn) Herbs
Vitamin Mineral Supplement
Selection of a V/M supplement:Full spectrum vitamins & minerals
Fat soluble vitamins (A, D, E, K)
Vitamin B complex (B1, B2, B3, B5, B6, B12, folic acid, biotin)
Vitamin C Minerals (calcium, magnesium, zinc, selenium, manganese,
chromium, molybdenum)
100 – 300% RDA
Vitamin Mineral Supplement
Approaches to get child to take supplement:
1. Incorporate into child’s Behavior Therapy Program
2. Oralflo pill swallowing cup
3. Pill Swallow Program
4. Negotiation
5. Mix supplement into food or beverageBook: “Eating for Autism”, Chapter 3
Elizabeth Strickland, MS, RD, LD
Vitamin Mineral Supplement
Mix in: Beverages Juice box Fruit smoothie Fruit sorbet Rice dream Yogurt, pudding, custard Peanut butter Fruit preserves Honey Ketchup Cooked foods (after cooking) Popsicles (homemade) Coromega®
Omega-3 Fatty Acids Supplement
“Most U.S. children do not consume anadequate amount of Omega-3 fatty acids intheir diet and Omega-3 fatty acids are essentialfor brain function and vision processing. Addinga daily Omega-3 fatty acid (EPA + DHA)supplement to the autistic child’s treatment planis warranted.”
Elizabeth Strickland, MS, RD, LD
Omega-3 Fatty AcidsDeficiency of Omega-3 fatty acids are linked to:
AutismADHDDyslexiaDyspraxiaDepressionAnxiety
Omega-3 Fatty Acids Neurodevelopmental Disorders: Numerous studies indicate that Omega-3 fatty acids
are deficient in ADHD, dyslexia, and dyspraxia. These neurodevelopmental conditions have a degree
of overlap with autism. Abnormalities in fatty acid metabolism may account for
many features common in these conditions.
Fatty Acid Metabolism in Neurodevelopmental Disorder: A New Perspectiveon Associations Between Attention-Deficit/Hyperactivity Disorder, Dyslexia,
Dyspraxia and the Autistic SpectrumProstaglandins Leukot Essent Fatty Acids 2000;63:1-9
Richardson AJ, et al
Omega-3 Fatty Acids Autism Spectrum Disorder: Studies to assess essential fatty acids for their
role in autism report essential fatty acid deficiency in children with autism.
“Reported DHA 23% reduced, total Omega-3 20%reduced, and Omega-6 unchanged in plasma.”
Plasma Fatty Acid levels in Autistic ChildrenProstaglandins Leukot Essent Fatty Acids 2001:65:1-7
Vancassel S, et al
Omega-3 Fatty Acids“Supplementing children’s diets with Omega-3 fatty acids improves poor learning and behavioral problems.”
Journal of the Developmental and Behavioral PediatricsApril 2007
“Supplementing with Omega-3 fatty acids decreased hyperactivity in children with autismspectrum disorders.” Biological Psychiatry 2007
Omega-3 Fatty AcidsMany research studies indicate that supplementing
with Omega-3 fatty acids reduces:
HyperactivityInattentionImpulsivityAnxietyCognitive problems
Omega-3 Fatty Acids
Functions of Omega-3 Fatty Acids:Brain development of the fetus, infant
and young childMaintenance of normal brain function
throughout lifeVital for brain cell signalingProminent structural fatty acid in the gray
matter of the brain & retinol tissue
Omega-3 Fatty AcidsOmega 6
↓
Linoleic Acid↓
Gamma-Linoleic Acid(GLA)
↓Arachidonic Acid (ARA)
↓Prostaglandin (PG1 & 2)
Omega 3↓
Alpha Linolenic Acid (ALA) ↓ delta-6 desaturase
Eicosapentaenoic Acid (EPA)↓
Docosahexaenoic (DHA)↓
Prostaglandin (PG1)
Omega-3 Fatty AcidsAdequate intake of Omega-3 Fatty Acids:
Age EPA + DHA (combined)
1 – 3 years old 70 mg/day
4 – 8 years old 90 mg/day
9 – 13 years 120 mg/dayFood and Nutrition Board
Institute of Medicine, National Academies
Omega-3 Fatty AcidsAdequate intake of Omega-3 Fatty Acids:
Age EPA + DHA (combined)
1 – 3 years old 390 mg/day
4 – 6 years old 540 mg/day
7 years & older 650 mg/day
National Institutes of Health (NIH)
Omega-3 Fatty AcidsSource EPA + DHA (mg/oz.)Salmon, Atlantic, farmed 608Herring, Pacific 602Herring, Atlantic 571Salmon, Atlantic, wild 521Tuna, fresh (blue fin) 426Mackerel, Atlantic 341Trout, mixed species 265Flounder 142Halibut 132
USDA Nutrient Data Laboratory
Omega-3 Fatty AcidsFDA & EPA recommendations for women who are or maybecome pregnant and nursing mothers: Do NOT eat shark, swordfish, king mackerel, and tilefish. Limit canned albacore “white” tuna to 6 ounces per week. Limit tuna steak to 6 ounces per week. Limit other fish and shellfish to 12 ounces per week. Check local advisories on safety of fish caught in your local
waters. *If no advisory, limit to 6 ounces and
do not eat any other fish that week.
Omega-3 Fatty AcidsThere are no recommendations for the
amount of fish that is safe for children.
FDA & EPA suggest to follow above
recommendations, but serve smaller
portions sizes.
Omega-3 Fatty AcidsSupplements EPA + DHACod liver oil (liquid) 1,035 mg / teaspoon
Coromega™ (original) 580 mg / packet
*Arctic cod liver oil 207 mg / soft gel
*DHA Junior 52 mg / soft gel
*Nordic Omega-3 Gummies 68 mg / gummy
*Nordic Naturals® products
Common Fortified Foods:
Omega-3 enriched eggs
Milk, Orange Juice, Yogurt, Smart Balance Spread
Additional SupplementsImmune System“Many medical professionals in the autism community believeautistic children are prone to immune system dysfunction.”
Studies indicate that autistic children exhibit atypicalimmune function: Abnormalities in T cells and T cell subsets Depressed responses to T cell mitogens Decreased natural killer cell function Lower percentage of helper-inducer cells Elevation of interleukin-12 Elevation of interferon-gamma Elevation of alpha-interferon levels Deficient form of the C4Bgene Antibodies to myelin basic protein & neuron-axon filament protein
Children with Starving Brains a Medical Treatment Guide for Autism Spectrum DisorderJaquelyn McCandless, MD
Additional SupplementsSupplements to enhance the immune system: Vitamin A Vitamin D Vitamin E Vitamin C Zinc Iron Magnesium Selenium Dimethylglycine (DMG)
Additional Supplements
Supplements to enhance cognitive function:IronZincCholineCoenzyme Q10 (CoQ10)CarnitineGinkgo biloba
Additional Supplements
Detoxification System It is a common belief in the autism community that
autistic children have a dysfunctional detoxification system within their liver.
It is believed that autistic children can not effectively excrete toxins out of their body.
These toxins (mercury, lead, arsenic, pesticides, herbicides, and other chemicals) cross into the brain, cling to brain tissue, and damage the brain.
Autistic children may be more vulnerable to neurological damage caused by exposure to toxins.
Additional SupplementsSupplements to enhance the detoxification system:
GlutathioneVitamin CSeleniumAlpha-Lipoic AcidN-acetylcysteine (NAC)Trimethylglycine (TMG)Milk thistle
The 10 – Step Nutrition Plan
1. Transition to a healthy diet2. Consume adequate basic nutrients3. Select a multi vitamin/mineral supplement4. Select an omega-3 fatty acid supplement5. Treat child’s feeding problem6. Heal the gastrointestinal tract7. Identify and treat food allergies8. Consider special diets9. Trial response of high dose vitamin B610. Consider additional supplements