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Nutritional Considerations in Autism Spectrum Disorders. Anne Roland Lee, MSEd, RD Nutritionist Celiac Disease Center Columbia University. Leaky Gut Maldigestion Malabsorption Bacterial overgrowth Gastrointestinal symptoms. Common Gastrointestinal Issues. Protein Vitamins:

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nutritional considerations in autism spectrum disorders

Nutritional Considerationsin Autism Spectrum Disorders

Anne Roland Lee, MSEd, RD

Nutritionist

Celiac Disease Center

Columbia University

common gastrointestinal issues
Leaky Gut

Maldigestion

Malabsorption

Bacterial overgrowth

Gastrointestinal symptoms

Common Gastrointestinal Issues
potential nutritional deficiencies
Protein

Vitamins:

C, E, B- complex, B 6

Minerals:

Calcium, magnesium, chromium

Calories

Fiber

Potential Nutritional Deficiencies
common nutrition profile
Lower serum magnesium

Lower B6 level

Elevated copper levels

B 12 deficiency

Common Nutrition Profile
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

Nutritional Treatments
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

Beyond the Diet
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

Gluten Content of Foods
nutritional deficiencies of gluten free diet
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
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
Health Concerns
  • Low nutrient density of commonly consumed gluten-free products
  • Potential side effects of usual gluten free diet:
    • Overweight
    • Constipation
    • Elevated lipids
health concerns12
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 concerns13
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
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
Comparison of gluten-free and wheat based products
  • Gluten-free products
  • Increased:
    • Fat
    • Calories
  • Decreased:
    • Fiber
    • B- Complex vitamins
    • Minerals
comparison of starches
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
dietary comparisons
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
sensory benefits
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 benefits24
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
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
slide26

Table 4

Significant at a 5% confidence interval excluding cereal & cake

slide27

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

recommendations
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
casein content of foods30
Hidden sources

Packaged mixes

Sauces

Baked products

Snacks and snack bar

****CAREFUL LABEL READING****

Casein content of foods
gfcf diet
Nutritional deficiencies

Vitamins

B –complex,

Minerals

Calcium, Iron

Fiber

Potentially macronutrients also

Protein, calories

GFCF Diet
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

Nutritional Approach to GFCF
practical approach
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

Nutritional Approach to ASD
beyond the diet35
Other considerations;

Texture

Aroma

Color

Shape

Wet vs. dry foods

Temperature

Beyond the Diet
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
diet recommendations39
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
diet recommendations40
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
diet recommendations41
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
diet recommendations42
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
diet recommendations44
Texture

Meats:

Cook tender

Ground meat in sauces

Vegetables

Pureed in sauces

raw

Fruits

Raw

Cooked then dried off

Diet Recommendations
diet recommendations45
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
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

Supplementation
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

Take home message