Autism, Diet, and Nutrition: Are You What
You Eat?
Susan L. Hyman, M.D.Golisano Children’s Hospital at Strong
June 2009
Dr. Hyman has nothing to disclose related to this presentation.
With Thanks to Patricia A. Stewart, Ph.D. R.D.
Objectives
• Review diagnosis of Autism• Describe food related behaviors in ASD• Examine nutritional effects of food refusal• Review nutrition in children with/without Autism
• Examine a specialized diet used for children with Autism
Autism Spectrum Disorders
•Qualitative abnormality of social give and take
•Qualitative abnormality of language used for communication
•Restricted and repetitive behaviors
•Onset less than 3, not better explained by another diagnosis
Autism Spectrum Disorders
Pervasive Developmental Disorder – Not Otherwise Specified
Rett Disorder
Asperger Disorder
Autism
Associated Symptoms Might Include:
• Seizures• Regression• GI Symptoms• Sensory Symptoms:
-Hyperacusis-Tactile Hypersensitivity-Food Aversion
Are GI Symptoms More Common in Children with ASD?
Chronic
Abdominal Pain
Food Aversions
Chronic Vomiting
Chronic Diarrhea
Reported in 18-72% of children with ASDs
– Increased rate at dx not supported by UK GP Database
– In RUPP cohort, 22%, associated with increased irritability
Why might there be an association of ASDs and GI symptoms ?
• Serotonin metabolism in ASD:- Increased plasma levels- Serotonin: NT in enteric
NS•Vagal nerve is bidirectional•Immunologic factors?•Embryologic or genetic events in common?
GI Questions (continued)
GI Questions (continued)
Lymphonodular hyperplasia in colon - Are the findings due to constipation? Need
to compare to controls with similar GI symptoms – MacDonald, 2007
- Is this autistic enterocolitis? – Wakefield, 2000
- Limited evidence to date for increased gut permeability
Celiac Disease, Allergies and Leaky Gut in ASD:• No increase in celiac disease (gluten enteropathy on an
autoimmune basis)• No increase in general food allergies, may be an increase in
milk allergy (Lucarelli, 1995)• Urine Peptide measurement controversial:
- Shattock (1991), Reichelt (1991), Cade (2000) report increased urinary peptides that suggest gluten and casein peptides
- Hunter et al (2003) or Cass (2008)could not confirm this
finding using more specific technology and did not identify a
difference in DPP IV
Feeding Problems and Autism:Author N Prevalence Discussion
Raiten and Massaro, 1986
40 ASD34 TD
Food idiosyncracies in 53% v. 18%, won’t chew 17.5% v. 6%
No difference in preference for same foods or refusal/dislikes
Schreck et al, 2004
138AD298 TD
Food refusal more common with ASD
Ate fewer foods within each food group
Schreck and Williams, 2006
138AD 72% restricted, 57% refusal (touching, presentation, texture, oral motor)
Preferred fewer foods than their families, family greater influence than ASD!
Valicenti-McDermott, 2006
56 ASD50 DD50 TD
Selectivity 60% ASD, 36% DD, 22% TD
Smelling and not mixing foods more common in ASD
BAMBI (Brief Autism Mealtime Behavior Inventory)- Lukens and Linscheid, 2008
• 18 item parent report scale• Specific for behaviors children with ASD exhibit at mealtime e.g. SIB, food aversions, aggression, rituals•Three factors: Limited variety, food refusal, features of autism•Validity: 24 hour food record, BPFAS
Food refusal in ASD may be secondary to:•Obsessions •Perseverative interests•Sensitivity to taste and/or smell of food •Sensitivity to texture•Food neophobia (fears)•Operant behavior
- Learned aversion- Punishment e.g. pain
Food Neophobia is a fear of new foods (not limited to ASD):
• Rare in infancy (Addessi et al., 2005) • Peaks after 2 yrs, decreases, then is stable 3-12 yrs (Carruth & Skinner, 2000)
•Associated with a limited diet in adolescence (Nicklaus et al., 2005)
• Autonomic arousal in children 7-12 (Pliner & Melo, 1997)
• Abnl taste and smell discriminated children with ASD from FXS and other delays (Rogers et al., 2003)
• Parent report of atypical smell sensitivity (Nieminen-von Wendt et al., 2005)
• Impaired odor identification in adults with Asperger syndrome (Suzuki et al., 2003)
• Impaired taste and smell identification in adolescents with ASD (Bennetto et al, 2007)
Atypical Sensory Processing in ASD
• Heritability of food preference - Olfaction genes - Taste genes, e.g. bitter taste appreciation associated with aversion to certain textures - Modest heritability of food preference in twins demonstrated (Breen et al., 2006)
• Environmental influences - Exposure influences preference - Schreck and Williams, 2006: in ASD, Food restriction related to family preferences
Why is this Important? It informs treatment for food refusal:
• Consistent meal time expectations• Repetition repetition repetition• Attention to sensory aspects of mealtime
- Quiet environment- Texture, taste and smell of food
• Model mealtime behavior Teachers, parents, peers
Children in the US are OverfedBut Undernourished
0
20
40
60
80
100
120
6-11 Mo. 1 Yr. 1-4 Yrs. 5-8 Yrs. 9-14 Yrs. 15-19 Yrs.
Critical Age
Critical Age
% Children Consuming
Daily Recommende
d Intake
Data compiled by Dr. John Lasekan, Ross Labsfrom NHANES 1999-2000 and the Continuing Food Survey 1994-96, 1998
Nutritional Intake of TD ChildrenFITS (Devaney 2004) N=703
<12 months – mean intake > AI for all nutrients 12 – 24 months – prevalence of inadequacy low for most
nutrients 58% had Vit E intake <EAR
Suitor, 2002 - CSFII 1994 – 96 Vit E – high % of children with intakes < EAR Folate and Mg – many children < age 9 with intakes < EAR Ca – females 9+ < AI Females 14 – 18 highest risk of intakes < RDA Few males met EAR for Vit E and Mg
Healthy Eating Index - USDA
36%
17%
12%
60%
76% 80%
4% 7% 8%
0%
20%
40%
60%
80%
100%
Good Improve Poor
Children 2 -3
Children 4 - 8
Children 7-9
Nutrition in children with Autism:Raiten & Massaro 1986
40 ASD34 TD
7 d diet; no difference between groups
Ho et al. 1997 54 ASD 3 d diet; 33% of un-supplemented low in Ca; 7.4% met Canadian RNI
Cornish 1998 17 ASD 3 d diet & FFQ; low RNI for 53% in one or more of Fe, niacin, riboflavin, B6, Ca, Zn, Vit D, & Vit C
Lindsay et al. 2006 20 ASD FFQ; Mean intake exceed DRI, but individual deficiencies in Ca, B5, Vit D, Vit K
Lockner et al. 2008 20 ASD20 TD
3 d diet; similar nutrient intakes
Herndon et al. 2008 46 ASD31 TD(14 GFCF)
3 d diet; ASD higher vitamin B6 & E, lower calcium, (when exclude GFCF, only B6 diff).
Dosman et al. 2007 43 ASD Fe Insufficiency: 2-5 yr, 69%; 6-10 yr, 35 %
Johnson et al. 2008 19 ASD15 TD
24 hr recall & FFQ; ASD lower percent met vitamin K; greater percent with Mg adequacy
Nutritional Consequences in ASDCase Reports Scurvy (2), Rickets (3), Vitamin A Deficiency (2),
Kwashiorkor (1)
Latif et al. 2002 52 Aut44 AS
11.5% Aut were anemic; 23 Aut had serum ferritin, 50% showed iron deficiency; lower rates of deficiency & anemia in AS vs Aut
Arnold et al. 2003
36 ASD(10 GFCF)24 DD
Decreased essential amino acids, GFCF lower in TRP
Dosman et al. 2006
96 ASD Fe Deficiency: 1-2 yr, 8.3%; 3-5 yr, 14.3%; 6-10 yr,20% (CDC: 7%, 5%, 4% respectively)
Hediger et al. 2008
75 ASD males
Decreased bone cortical thickness; effect greater on casein free diet
1963-67 1971-74 1976-80 1988-1994 2003-06 1966-70 1999-2002
Percent
2010 Target: 5%
Decrease desired
*Data for 1966-70 are for adolescents 12-17 years of age.Note: Overweight is defined as BMI ≥ gender- and age-specific 95th percentile from the 2000 CDC Growth Charts for the United States. Source: National Health Examination Surveys II (ages 6-11) and III (ages 12-17), National Health and Nutrition Examination Surveys I, II, III and National Health and Nutrition Examination Survey, NCHS, CDC.
Obj. 19-3a, b
1963-65 1971-74 1976-80 1988-1994 2003-06 1966-70* 1999-2002
Child and Adolescent Overweight
Male 12-19Male 6-11Female 12-19Female 6-11
40
30
20
10
0
Body Mass Index (BMI)Mouridsen et al. 2002 117 ASD Lower BMI distribution of male, but not female;
32% males below 10th percentile
Whiteley 2004 50 ASD 58% above >75th Percentile, 42% overweight, 10% exceeded cutoff for obesity
Curtin et al. 2005 42 ASD ASD: 35.7% at risk overweight, 19% overweight Similar prevalence of overweight
Hediger et al. 2007 75 ASD males
ASD males taller, heavier, higher BMI than average; 18.7% in 85th-95th percentile; 26.7% in >95th percentile
Mouridsen et al. 2008 198 ASD Lower BMI distribution of male, but not female; ~15% of males had BMI below 5th percentile
National Children’s Health Study
483 ASD No difference in BMI for ASD
STAART, Rochester Mean BMI 62nd percentile; not overweight
Dietary Treatments for Symptoms of Autism:
• Complementary therapies popular
- Levy et al (2003) – 30% of children with ASD on dietary interventions by time of diagnosis
• Interactive Autism Network (IAN) survey
- 54% respondents using supplements
- 30% using dietary intervention
Why a Gluten free and Casein free diet as an intervention for Autism?
• Clinical observations of behavioral improvement in single cases using elimination diets (1970s)
• Hypothesis (Shattock; Reichelt) that opiate-like peptides (proteins) in foods containing casein or gluten act like false neuropeptides and cause or increase symptoms of autism.
• Cass et al (2008) did not confirm presence of urinary peptides
Opioid Related
Gastro-
Intestinal
Peptide Related
Immune Dysregulation/ Autoimmune related
From Christison & Ivany, 2006
Absorption of opioid peptides across a leaky gut
Decreased peptidase activity leading to peptide leakage
Gluten or casein leads to mucosal inflammation
Antibodies to dietary peptides react with CNS antigens
CaseinFoods to Avoid
• Dairy (Milk, yogurt, butter, cheese, cream, cream cheese)– casein, caseinate, lactose, whey
Foods to Check (may contain casein)• Baked goods (bread, pastries, pies)• Non-dairy creamer (will say “milk” in ingredients)• Whipped Topping• Soy Cheese• Candy• Sauce (tomato, pesto)• Salad dressing• Cereals
Sounds like Dairy/Milk, but does not contain milk• Calcium lactate, calcium/sodium stearoyl lactylate, cocoa butter,
cream of tartar, lactic acid, sodium lactate
Casein = Lactose
GlutenFoods to Avoid
• Wheat – wheat starch, wheat bran, wheat germ, cracked
wheat, hydrolyzed wheat protein – einkorn, emmer, spelt, kamut, faro– durum, graham, semolina
• Barley• Rye• Triticale (cross between wheat & rye)• Malt, malt flavoring, malt vinegar (generally made from
barley, verify the source)
Gluten
• Bouillon cubes
• Brown rice syrup
• Candy
• Chips/flavored potato chips/seasoned tortilla chips
• Cold cuts, hot dogs, salami, sausage
• Communion wafers
• French fries
• Gravy
• Vegetables in sauce
• Breading & coating mixes
• Imitation seafood/ fish• Matzo• Rice mixes• Sauces• Self-basting turkey• Soups• Soy sauce• Energy bars• Imitation bacon• Marinades• Herbal & nutritional supplements• Drugs & OTC medication• Play-Doh ©
Foods to Check (may contain gluten)
OatsNeed to be certified gluten-free
• Oats do not contain gluten, but may be contaminated with wheat during processing
• Celiac.org no longer strictly limits oats
The Challenge of Introducing New Foods:
•Complexities of gluten free baking
•Taste, texture and acceptability issues
Nutritional Characteristics of the GFCF diet
• Elimination of milk protein (casein)• Elimination of Wheat, Barley, and Rye products
(contain gluten)
• Oats inherently do not contain gluten, but they may be contaminated during processing
• Diet inherently deficient in calcium and vitamin D
GFCF StudiesThere have been 8 clinical trials, but only 2 were controlled studies
Author Design N Measure Outcome
Knivsberg
2002
Single blind,
Peptide pattern
20 ITPA, DIPAB
Over 1 yr
Significant effect in: overall autistic traits, social interaction, and ability to communicate & interact
Elder
2006
Double blind,
placebo controlled, crossover
15 CARS, EOC No change
Baseline
Establishment of the GFCF diet (two weeks)
4 weeks on GFCF diet
12 weeks of double blind placebo controlled challenge snacks (gluten, casein, gluten and casein, placebo)
Follow up at 30 weeks
STAART Diet Study Protocol
Cochrane Library 2008
• Millward et al, Gluten and casein-free diets for autistic spectrum disorder.
– “Current evidence for efficacy of these diets is poor”.
GFCF Nutritional Consequences
Hediger et al. 2007 75 ASD males
Effect of decreased bone cortical thickness in ASD males greater on casein-free diet
Herndon et al. 2008 46 ASD31 TD(14 GFCF)
More Vit E & less Ca than control
Cornish 2002 37 ASD(8 GFCF)
No differences in nutrient intake on/off diet
What’s Listed on a Food LabelLabels must clearly identify the source of all ingredients that are (or
are derived) from the 8 most common food allergens.• Milk• Eggs• Fish (bass, flounder, cod)• Crustacean Shellfish (crab, lobster, shrimp)• Tree nuts (almonds, walnuts, pecans)• Peanuts• Wheat• Soy
Ingredient labels must use the common name “MILK” to identify dairy-containing foods
Wheat-Free does not mean Gluten-Free
Food Allergen Labeling & Consumer Protection Act (FALCPA)
OPTION 1Ingredients: Enriched flour (wheat flour, malted barley, niacin, reduced iron, thiamin mononitrate, riboflavin, folic acid), sugar, partially hydrogenated soybean oil, and/or cottonseed oil, high fructose corn syrup, whey (milk), eggs, vanilla, natural and artificial flavoring, salt, leavening (sodium acid pyrophosphate, monocalcium phosphate), lecithin (soy), mono- and diglycerides (emulsifier)
OPTION 2Contains Wheat, Milk, Eggs and Soy
"These statements are not required if the major food allergen's common name already identifies its food source," For example, the ingredients whole wheat flour, buttermilk, and peanut butter already state that they contain wheat, milk, and peanuts, respectively, so no further explanatory terms are required.
How Daily Values (DV) compare in ChildrenNutrient DV 2 - 3
years4 - 8 years 9 - 13
years14 - 18 yr
girls14 - 18 yr
boys
Iron (mg) 18 7 10 8 15 11
Calcium (mg)
1,000 500 800 1300 1300 1300
Vitamin A (IU)
5000 1000 1333 2000 2333 3000
Vitamin C (mg)
60 15 25 45 65 75
%DV is based on adults.
Flintstone’s Vitamins
Flintstone’s Vitamin Analysis
1%2%190015002%3%1200100025Sodium (mg)
75%100%400300150%200%200150300Folate (mcg)
5%8%300200214%250%7615Vitamin E (mg alpha
tocopherol)
20%20%20002000200%200%200200400Vitamin D (IU)
38%63%6504001000%1667%2515250Vitamin C (mg)
NANANDND375%500%1.20.94.5Vitamin-B12 (mcg)
3%4%4030175%210%0.60.51.05Vitamin-B6 (mg)
90%135%1510169%225%8613.5Niacin-B3 (mg)
NANANDND200%240%0.60.51.2Riboflavin-B2 (mg)
NANANDND175%210%0.60.51.05Thiamin-B1(mg)
83%125%30002000188%250%133310002500Vitamin A (IU)
%UL(4-8)
%UL(1-3)
UL (4-8)
UL (1-3)
%RDA(age 4-8)
%RDA(age 1-3)
RDA(age 4-8)
RDA (age 1-3)VitaminNutrient
1%2%190015002%3%1200100025Sodium (mg)
75%100%400300150%200%200150300Folate (mcg)
5%8%300200214%250%7615Vitamin E (mg alpha
tocopherol)
20%20%20002000200%200%200200400Vitamin D (IU)
38%63%6504001000%1667%2515250Vitamin C (mg)
NANANDND375%500%1.20.94.5Vitamin-B12 (mcg)
3%4%4030175%210%0.60.51.05Vitamin-B6 (mg)
90%135%1510169%225%8613.5Niacin-B3 (mg)
NANANDND200%240%0.60.51.2Riboflavin-B2 (mg)
NANANDND175%210%0.60.51.05Thiamin-B1(mg)
83%125%30002000188%250%133310002500Vitamin A (IU)
%UL(4-8)
%UL(1-3)
UL (4-8)
UL (1-3)
%RDA(age 4-8)
%RDA(age 1-3)
RDA(age 4-8)
RDA (age 1-3)VitaminNutrient
Autism Treatment Network:
Goal to Set Best Practices for Medical Management of children with ASD15 sites across the US and CanadaTargeted areas of interest:
GI symptomsSleepNeurologic/metabolic/genetic evaluations
AIRP - Diet and Nutrition Provide prospective and accurate data to allow for guideline development regarding diet and nutrition for children with ASD
Obtain accurate data regarding What Children with Autism Eat in America, a topic of great interest to parents and clinicians
– Are diets with limited variety providing adequate nutrition?– Do commonly used supplements have side effects?– Are low iron stores associated with sleep problems?– Could diet be related to GI symptoms?
Child
ren
with A
utism
Summary:•You are what you eat: Parents of children with ASD should be counseled by their health care provider regarding nutrition and health in children
• Families whose children take restricted diets or therapeutic supplements may benefit from consultation with a Nutritionist
• Clinical trials will assist in evidence based decision making
•Do ask, do tell: Familes should tell their Health Care Provider about supplements and dietary interventions and Health Providers should ask
•Review the data supporting – and refuting – nutritional interventions: Nutrition does affect behavior and overall health in children with and without ASD
Science is facts; just as houses are made of stone, so is science made of facts; but a pile of stones is not a house, and a collection of facts is not necessarily science. Jules Henri Poincaré (1854-1912) French mathematician.
Shall I refuse my dinner because I do not fully understand the process of digestion?
Oliver Heaviside (1850-1925) English physicist.
Acknowledgements:• Patricia Rodier• Loisa Bennetto• Carol Stamm• Tristram Smith• Danielle Morris• Jennifer Foley• Joy Valvano• Robin Peck• Usa Cain• Kay Valerioti• Jennifer Handzel• Jonathan Mink•Joshua Diehl•Philip Ng
• Jennifer Kwon• Eileen Blakely• Laura Silverman• Emily Kuschner• Betsy Smith• Mariellen Cupini• John McEachen• Doreen Greenspesheh• Denise Rhine• Jack Bennetto• Emily Healy• Meaghan Miller• General Clinical Research Center 5MO1RR00044• STAART (NIMH)U54MH066397•ATN/Autism Speaks
And the children and families of children with autism in upstate NY who helped identify the problems and are
helping to find the answers.
AIRP Acknowledgements:
Autism Speaks/Autism Treatment Network, NCC and Jim Perrin,
Leann Birch, Usa Cain, NDSR, and Traci Clemons
Top Related