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Nutritional Considerations in 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 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 160 140 120 100 Regular Pretzels 80 GF Pretzels 60 40 20 0 Calorie Protein Fat Iron Calcium Comparison of Pastas 12 10 8 Regular Spaghetti 6 GF Bean GF Corn 4 2 0 Protein Fat Fiber Thiamin Riboflavin Niacin Iron Calcium 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 12 10 8 Rice, White Millet Millet, Puffed 6 Quinoa Potato, Baked Potato, Boiled 4 2 0 Protein Fiber Thiamin Riboflavin Niacin Iron 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 700 600 500 400 Standard Alternative 300 200 100 0 Calories Protein Fiber Thiamin Riboflavin Niacin Folate mcg Iron Calcium Grain Comparisons Grain Protein Fiber Rice* (Enriched) Thiamin Niacin Folate Millet Teff Buckwheat Quinoa Sorghum flour Chickpea flour Iron Calcium 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 National Comparison of Regular and Gluten-Free Products Table 4 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 Regular Gluten-Free 1.00 0.90 Figure 3 0.80 0.70 Price per ounce 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Bread Cereal Waffles Crackers Cookies Pretzels Pasta Pizza Comparison of Regular and Gluten-Free Products: Values are mean of price per ounce of all venues in all regions Macaroni & Cheese Cake 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