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

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

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