Download Diet and Autism - Virginia Head Start Association, Inc.

CURRENT EVIDENCE FOR DIET
THERAPIES IN THE TREATMENT
OF AUTISM SPECTRUM
DISORDER
Melissa Gutschall, PhD, RD, LDN
Assistant Professor and Director, Didactic Program in Dietetics
Appalachian State University
Consultant Dietitian: Southwest Virginia Care Connection for
Children (Virginia Department of Health/University of Virginia)
Definitions

Autism Spectrum Disorder (ASD)



Autistic Disorder


“This is what most people think of when hearing the word "autism." People with autistic
disorder usually have significant language delays, social and communication challenges,
and unusual behaviors and interests. Many people with autistic disorder also have
intellectual disability.” It is the most severe.
(http://www.cdc.gov/ncbddd/autism/facts.html)
Asperger Syndrome


“Complex developmental and neurological condition that typically appears during the first
three years of life. It affects brain function, particularly in the areas of social interaction
and communication skills.”(eatright.org)
It is a spectrum from mild to severe
“People with Asperger syndrome usually have some milder symptoms of autistic disorder.
They might have social challenges and unusual behaviors and interests. However, they
typically do not have problems with language or intellectual disability.”
(http://www.cdc.gov/ncbddd/autism/facts.html)
Pervasive Developmental Disorder (PDD-NOS)

“Diagnosis applied to children or adults who are on the autism spectrum but do not fully
meet the criteria for another ASD such as autistic disorder or Asperger Syndrome.”
(http://www.autismspeaks.org/what-autism/pdd-nos)
Characteristics

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Little or no eye contact
Nonresponsive to verbal cues
Difficulty expressing needs
Repetitive words and phrases
Insistence on sameness
Little social interaction; prefers to be alone
Tantrums
Inappropriate attachment to objects
Prevalence


1 in 88 children
More common in boys
1
in 54 boys
 1 in 252 girls

1% of North American Population
 Centers for Disease Control, 2012
Risk Factors




Older parents
Being a male
Having a parent or sibling with the disorder
Epilepsy and genetic disorders such as:
 Fragile
X syndrome
 Tuberous sclerosis
 Tourette Syndrome
 Down Syndrome

Pre-, peri-, and neonatal factors
PROPOSED DIET THERAPIES
Proposed Diet Therapies

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Gluten Free/Casein Free
Food Rotation
Specific Carbohydrate
Gut and Psychology Syndrome Diet (GAPS)
Body Ecology Diet
Feingold and Failsafe Diets
Raw Food Diet
Antioxidant Diet
Ketogenic Diet
Weston A Price Foundation/Traditional Diet
Gluten and Casein Elimination Diet
(GF/CF)

Complete removal of gluten and casein
 Gluten
(found in wheat, rye, barley, oats)
 Casein (found in milk and milk products)
Evidence for Gluten and Casein
Elimination diet

Double-blind study on 15 children of a gluten free,
casein free diet (Elder et al, 2006)


Dietary intervention on 149 children (Elder et al, 2006)



Notable reports of children being “cured” and acquiring language
skills and marked social connectedness.
81% improvement shown in 3 months of intervention
Most assessments were made by parents who knew their child
was on the diet.
Single-blind study on 10 children in both patient and
control group (Knivsberg et al, 2002)


Observations were performed before and after 1 year.
Statistically significant improvements with respect to aloofness,
routines and rituals, and responses to learning.
Evidence for Gluten and Casein
Elimination diet (cont.)

Antibodies against gliadin, casein, brain myelin basic
protein, egg, corn, and soy measured in 50 children
with autism (Vojdani, Pangborn et al, 2003)


Significant numbers of children with antibodies against
casein and gliadin which can trigger inflammation and
immune response.
Benefits of the diet using the Childhood Autism Rating
Scale (CARS); participants given a supply of compliant
food (Elder et al, 2006)

No statistical significance was found in the CARS scores,
but anecdotal reports found decreased hyperactivity and
tantrums and increased language in 7 children.
Ingredients to Avoid Casein


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Casein (sodium caseinate,
hydrolyzed casinate)
Rennet casein
Whey
Milk solids
Lactose (sodium lactyate)
Lactalbumin, lactalbumin
phosphate, lactoglubulin,
lactoferrin
Galactose
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Caramel color
Natural ingredients (call
manufacturer)
Recaldent (ingredient in
whitening chewing gum)
Baked goods that contain
milk products
Butter
Cheese
Ghee
Yogurt
Ingredients to Avoid Gluten

Wheat (all kinds and forms)



Barley

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Spelt, kamut, einkorn, emmer, duram, semolina, triticale
Wheat bran, couscous, graham flour, matzo, wheat germ, cracked wheat, farina,
tabbouleh
Malt, malt flavoring, malt extract, malt syrup, malt vinegar
Rye
Untested Oats
Hydrolyzed wheat protein
Soy sauce (may be made with wheat, look for La Choy brand or one that
states gluten free)
Seasoning (may use wheat)
Marinades (may have wheat or barley)
Broth (may be made with wheat)
Foods to look for:

Gluten free
Rice
 Corn
 Buckwheat
 Millet
 Quinoa
 Bean flours
 Amaranth
 Arrowroot
 Sorghum
 Tef/teff
 Wild rice


Casein Free
Soy products (some
contain milk)
 Nut products
 Coconut
 Look for fortified milk
alternatives

Soy
 Almond
 Rice
 Hemp
 Coconut

Food Rotation Diet




Food rotation rather than elimination to evaluate
overall improvement in symptoms
Used in conjunction with antibody tests that can help in
determining which foods to rotate
Rotations can occur daily, weekly, or monthly
Eliminate most reactive foods, rotate less reactive foods
on a daily basis and consume primarily nonreactive
foods
Specific Carbohydrate Diet

Pioneered as a treatment for ulcerative colitis
(Gotschall, 1994)
 Designed
to heal intestinal permeability and combat
overgrowth of pathogens in the gut mucosa
 Started in autism to treat GI symptoms and possibly
behavior issues
 Carbohydrates that aren’t digested or absorbed stay in
intestinal tract and result in overgrowth of yeast and
bacteria, causing injury and impaired digestion
 Starve organisms to reestablish intestinal health
Specific Carbohydrate Diet

Eat single sugars
 fruits,
honey, properly made yogurt, and certain
vegetables

Allowed foods:
 proteins
(eggs, natural cheese, homemade yogurt)
 non-starchy vegetables (cabbage, cauliflower, onions,
spinach, peppers)
 variety of nut and nut flours (almonds, brazil nuts, walnuts)
 soaked lentils and beans

Prohibited foods:
 grains
or products with trace amounts of grains
Gut and Psychology Syndrome Diet
(GAPS)



Based on the Specific Carbohydrate Diet
Introduced in stages
The best foods to include:

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Fruits should be consumed on their own not with meals
because they have a different digestion pattern
At every meal consume

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Eggs, fresh meats (not preserved), fish, shellfish,
Fresh vegetables and fruits, nuts and seeds, garlic and olive oil
Consume both raw and cooked vegetables
natural fats
fermented foods
homemade meat or fish stock
Avoid processed foods
Body Ecology Diet


Rebuild immunity and intestinal flora (Gates, 2006)
Based on traditional healing principles using fermented foods (young
coconut kefir and cultured vegetables)

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Establishment of a slightly alkaline pH to enable beneficial flora to
flourish
Recommended:


Seaweed
Grains such as buckwheat, quinoa, millet, and amaranth.


Grains are soaked and fermented, sometimes sprouted to allow for easy
digestion.
Meals are balanced on a 80-20 rule.


Non-starchy vegetables make up the bulk with room for starchy
vegetables, proteins, and grains.
Dairy products aren’t allowed initially but eventually you add raw butter
later in the diet.
Feingold and Failsafe Diets
Elimination of food colors and flavors: nerve cell stimulation
(Feingold, 2002)
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Foods to avoid
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Group I foods containing natural salicylates: almonds, apples,
apricots, berries, cherries, grapes, nectarines, orange, peaches,
plums, prunes, tomatoes, cucumbers
Group II foods containing food additives and colors: factorymade cereals, instant breakfasts, baked goods, luncheon meats,
frozen fish, candies, soft drinks, desserts, and any other foods
containing food additives
The Failsafe diet reduces food additives, salicylates, amines
and flavor enhancers like MSG (Dengate, 2008)
Evidence for Feingold and Failsafe
Diets


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Elimination of food additives showed a decline in
symptoms of hyperactive patients (McCann et al, 2007)
Deficiency of phenol sulfur transferase which helps
break down salicylate phenols.
Symptoms of salicylate sensitivity:
dark circles under eyes
 hyperactivity
 difficulty falling asleep at night
 inappropriate laughing/giggling
 head banging

Raw Food Diet

Based on uncooked and unprocessed foods (Jeep et
al, 2008)
 Sprouts,
fresh fruits and vegetables, dried fruits, seeds,
nuts, gains, seaweed.
 Heating foods above 116 F is thought to destroy
enzymes
 Recommends soaking seeds and nuts and dehydrating
other foods.

Retaining natural enzymes and antioxidants in
nutrient dense foods
Antioxidant Diet
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Reduce oxidative stress, and thus inflammation, in an
overactive immune system (Johnson et al, 1972)
Recommended foods include:
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Fresh vegetables
Fresh fruits
Cooked legumes/starchy vegetables
Whole grains
Moderate amounts of lean meat
Super foods
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Broccoli
Brussels sprouts
Sea vegetables
Berries (blueberries, cranberries, goji berries)
Ketogenic Diet

Pilot study with 30 children using the John-Radcliffe
version for 6 months (Evangeliou et al, 2003)
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Energy intake distribution: 30% MCT oil, 30% fresh cream,
11% saturated fat, 19% carbohydrates, 10% protein
Evaluated using CARS scores before and after the
intervention
2
significant improvement
 8 average improvement
 8 minor improvement
Weston A Price Foundation Diet or
Traditional Diet

Consume unprocessed or minimally processed food
Traditional fats (animal fats, dairy fats, olive oil, cod liver oil)
 Organic fruits and vegetables
 Raw dairy products
 Soured or lacto-fermented dairy vegetables
 Whole grains (soaked or soured to neutralize phytic acid)
 Bone stocks

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Supports local foods and farms
Opposition to veganism and some aspects of vegetarianism
Summary of Diet Therapies

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Limited evidence
Contradictions and commonalities among the diets
Routine nature of a diet plan
Feasibility for family
Limiting foods vs. challenges of food acceptance
Nutritional Deficiencies
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Vitamin D levels are lower in autistic children
(Kocvaska, 2012)
Consumption of more vitamin B6, vitamin E and less
calcium (Herndon, 2009)
Low intakes of magnesium, zinc, selenium, vitamins
A, B-complex, D and E, omega-3 fatty acids, and
carnitine (Bandini et al, 2010)
Iron deficiency (Reynolds et al, 2012)
Reduced absorption of vitamin B12 (Ashwood and
Van de Water, 2004)
Evidence for Supplementation


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Use of a broad-based multivitamin and mineral supplement
reduced sleep and GI symptoms (Adams and Holloway,
2004)
Supplementing L-carnosine improved the Gilliam Autism
Scale (Chez et al, 2002)
Behavioral improvements when supplementing vitamin B6,
folate (Rimland, 1988), omega-3 fats (Amminger, 2007),
vitamin C (Dolske, 1993)
Oral supplementation with magnesium and vitamin B6
improved social interactions, communications and intellectual
function (Mousain-Bosc et al, 2006)
Daily supplementation of vitamin C and flax oil improved
inattention, hyperactivity, learning problems, and social
problems (Curtis, 2008)
Nutrition/Medication Interactions

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Anti-depressants (SSRI’s)
Antipsychotics
Stimulants
Affect appetite and weight
 Meal/medication regimen

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Anticonvulsants

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Calcium (600-1000 mg)/Vitamin D (2000-4000 IU)
Treat symptoms rather than cause
Nutrition Therapy Summary
(Adapted from Strickland E, “Eating For Autism”, 2009)
Heal the Child’s
Gut
Elimination/Challenge
Diet
Treat Feeding
Problems
Enhance
Cognitive
Function
Identify and
Treat Food
Allergies
Nutraceuticals
and Nutrients
Enhance
Detoxification
and Immune
Systems
References

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Elder JH, Shankar M, Shuster J, et al. The gluten-free, casein-free diet in autism results of a preliminary double blind clinical
trial. J Autism Dev Disord. 2006; 36:413-420.
Knivsberg, A. M., Reichelt, K. L., Hoien, T., & Nodland, M. (2002). A randomized, controlled study of dietary intervention in
autistic syndromes. Nutritional Neuroscience, 5, 251–261
Knivsberg, A., Reichelt, K. L., Nodland, N., & Hoien, T. (1995). Autistic syndrome and diet: A follow-up study. Scandinavian
Journal of Education and Research, 39, 223–236.
Vojdani A, Pangborn JB, Vojdani E, et al. Infections, toxic cheicals and dietary peptides binding to lymphocyte receptors and
tissue enzymes are major instigators of autoimmunity in autism. Int J Immunopathol Pharmacol. 2003; 16:189-199.

Gotschall E. Breaking the vicious cycle: intestinal health through diet Kirkton, Ontario, Canada: Kirkton Press; 1994.

Gates D. The body ecology diet. Bogart, GA: Body Ecology; 2006.
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Finegold, S. M., Molitoris, D., Song, Y., Liu, C., Vaisanen, M. L., Bolte, E., McTeague, M., Sandler, R., & Wexler, H.
Gastrointestinal microflora studies in late-onset autism. Clinical Infectious Diseases. 2002; 35: S6–S16.
Dengate S. Fed up. North Sydney, Australia: Random House Australia; 2008.
McCann D, Barrett A, Cooper A, et al. Food additives and hyperactive behavior in 3-year-old and 8/9-year-old children in
the community: a randomised, double-blinded, placebo-controlled trial. Lancet. 2007;370: 1560-1567.
Jeep R, Couey R, Pitman Ellington S. the super-antioxidant diet and nutrition guide. Charlottesville, VA: Hampton Roads
Publishing Company; 2008.
Johnson RR, McClure KE. High fat rations for ruminants. I. The addition of saturated and unsaturated fats to high roughage and
high concetrate rations. J Anim Sci. 1972; 34:501-509.
Evangeliou, A., Vlachonikolis, I., & Mihailidou, H. Application of ketogenic diet in children with autistic behavior: Pilot study.
Journal of Child Neurology. 2003; 18: 113–118.
http://en.wikipedia.org/wiki/Weston_A._Price_Foundation
Kocovska E, Fernell E, Billstedt E, Minnis H, Gillberg C. Vitamin D and autism: clinical review. Res Dev Disabil. 2012;
33(5):1541-50. Doi: 10.1016/j.ridd.2012.02.015
References
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Bandini LG, Anderson SE, Curtin C, Cermak S, Evans EW, Scampini R, Maslin M, Must A. Food selectivity in children with autism
spectrum disorders and typically developing children. J Pediatr. 2010; 157(2):259-64. Doi: 10.1016/j.jpeds/2010.02.013.
Reynolds A, Krebs NF, Stewart PA, Austin H, Johnson SL,Withrow N, Molloy C, James SJ, Johnson C, Clemons T, Schmidt B,
Hyman SL. Iron status in children with autism spectrum disorder. Pediatrics. 2012; 130; Suppl 2: S154-9. Doi:
10.142/peds.2012-0900M.
Ashwood P, Van de Water J. A review of autism and the immune response. Clin Dev Immunol. 2004;11:165-174.
Adams JB, Holloway C. Pilot study of a moderate does multivitamin/mineral supplement for children with autistic spectrum
disorder. J Altern Complement Med. 2004; 10(6):1033-9.
Chez MG, Buchanan CP, Aimonovitch MC, Becker M, Schaefer K, Black C, Komen J. Double-blind, placebo=controlled study of
L-carnosine supplementation in children with autistic spectrum disorders. J Child Neurol. 2002;17(11):833-7.
Rimland B. Controversies in the treatment of autistic children: vitamin and drug therapy. J Child Neurol. 1988;3:S68-S72.
Amminger GP, Berger GE, Schafer MR, et al. Omega-3 fatty acids supplementation in children with autism: a double-blind
ransomized, placebo-controlled study. Biol Psychiatry. 2007;61:551-553.
Dolske MC, Spollen J, McKay S. A preliminary trial of ascorbic acid as a supplemental therapy for autism. Prog
Neuropsychopharmacol Biol Psychiatry. 1993;17:76-774.
Mousain-Bosc M, Roche M, Polge A, Pradal-Prat D, Rapin J, Bali JP. Improvement of neurobehavioral disorders in children
supplemented with magnesium-vitamin B6. II. Pervasive developmental disorder-autism. Magnes Res. 2006; 19(1): 53-62.
Curtis L, Patel K. Nutritional and environmental approaches to preventing and treating autism and Attention Deficit
Hyperactivity Disorder (ADHD): A Review. Journal of Alternative and Complimentary Medicine. 2008; 14(1):79-85.
Ahearn, W. H., Castine, T., Nault, K., & Green, G. An assessment of food acceptance in children with autism or pervasive
developmental disorder-not otherwise specified. Journal of Autism and Developmental Disorders. 2001; 31: 505–511.
Latif A, Heinz P, Cook R. Iron deficiency in autism and Asperger syndrome. Autsim: The international journal of research &
practice. 2002; 6(1):103
Srinivasan P. A review of dietary interventions in autism. Annals of Clinical Psychology. 2009;21(4):237-247.
Herndon AC, DiGuiseppi C, Johnson SL, Leiferman J, Reynolds A. Does nutritional intake differ between children with autism
spectrum disorders and children with typical development?. J AutismDev Disord. 2009; 39(2): 212-22. Doi: 10.1007/s10803008-0606-2.
EATING BEHAVIORS
Dietary Management



Most individuals with autism have low levels of food
acceptance (Ahearn et al, 2001)
Most cases require trial and error
Record keeping is important to track and develop
dietary strategies

Add foods before you subtract

Eliminate processed foods first
“Picky Eating”

Sensory feeding problems
 Hypersensitivities
to textures, smells, temperatures, or
tastes


Slowed progression of feeding development
Symptoms from infancy
 Difficult/slow
feeders
 Late introduction of solids
Picky Eater vs. Problem Feeder

Picky eater






Eat more than 40 different foods
Will return to a food
Tolerates new foods on plate
Eats most food textures
15-25 exposures
Problem feeder





Eat less than 40 foods
Never return to a food
Breaks down when presented with new foods
Refuses entire categories of textures
>25 exposures
Possible reasons








Anxiety about unknown foods
Craving for certain foods
Dislike of foods related to GI upset
Loss of appetite
Sensations – acidity, bitterness, etc.
Deficiencies that may affect taste and sensory
perception
Oral motor issues
Food allergies
Selective Food Patterns Related to
Autism-Associated Behaviors

Behavior
 Need
for routine,
difficult with transitions
 Short
Attention Span

Effect on Eating
 Mealtime
routine
 Refusal of unfamiliar
food, dish or location
 Limited number of
accepted foods
 Loss
of interest in
eating after only a
few minutes
Selective Food Patterns Related to
Autism-Associated Behaviors

Behavior
 Sensitivity
 Easily
overwhelmed or
overstimulated
 Impaired
social
interaction

Effect on Eating
 Restricted/refused
intake due to
hypersensitivity
 Less
responsive to
positive eating
behaviors modeled by
others
INCORPORATING SENSORY
EXPERIENCES
Myth: “Eating is Easy”
Sensory Factors: Visuals

Stimulating

Calming
 Brand-packaging
 Monochromatics
 Bright,
 Large
multi-color,
small shapes, details
 Rapid movements
 Fluorescent lighting
 Total darkness
shapes, few
details
 Muted colors
 Slow movements
 Dark or low light
Sensory Factors: Textures

Stimulating

Calming
 Crunchy
 Gummy
 Hard
 Soft
 Thick
 Thin
 Hot/Cold
 Cool/Warm
 Gooey
 Silky
Sensory Factors: Smell

Stimulating

Calming
 Mint
 Lavendar
 Lemon
 Rose
 Cinnamon
 Clove
 Ammonia
 Vanilla
 Coffee
 Bergamot
Sensory Factors: Taste

Stimulating

Calming
 Sour
 Sweet
 Bitter
 Salty
 Spicy
 Umami
Sensory Factors: Sounds

Stimulating
 Chewing,
slurping,
scraping
 Loud, fast, erratic
 Major keys
 Rock, rap, hip-hop,
heavy metal

Calming
 Quiet
foods and
utensils
 Soft, slow rhythms
 Minor keys
 Classical, folk, country,
R&B
FEEDING SKILLS
Assessing Feeding Skills








Age vs. developmental level of child
Previous feeding experiences
Position
Texture/consistency of food and drink
Previous food challenges
Mouth movement and head position
Sensory aspects of feeding and tactile
defensiveness
Visual/auditory stimuli
Assessing Feeding Skills. . .






Smell of food
Temperature of food
Taste of food
Utensils used, amount of assistance needed
Fluid intake
Dental hygiene and oral health/chewing and
swallowing ability
Developmental Stages


Parallel eating and mealtime behaviors
Match goals to developmental window:
 Regulation
and Interest (0-3 months)
 Engagement and Attachment (3-6 months)
 Purposeful Communication (6-12 months)
 Sharing and Problem Solving (12-18 months)
 Creating Ideas (18-36 months)
 Connecting Emotions and Ideas (36-48 months)
 Self-reflection (4 yrs. +)
INTERVENTIONS
-PNCM, 2012
Myth: “She’ll eat when she’s hungry. . .she won’t
starve.”
Nutrition Interventions – Behavioral





Avoid overwhelming the child (offer manageable
foods)
Introduce foods in familiar forms
Slow, gradual changes
Consistent with other effective approaches
Feeding Therapy:
 Positive
Reinforcement; Non-food rewards
 Escape Extinction – non-removal of utensil or physical
guidance
 Stimulus Fading – increasing number of bites or amount
of food on spoon
Nutrition Interventions – Meal Pattern


Modify portion sizes
Adjust meal and snack schedule
Stop grazing-meals have a beginning and end
2 hours between meals and snacks
Avoid constant sweet drinks
Nutrition Interventions – Feeding
Environment






Structure – same time each day
Appropriate feeding equipment
Feeding time
Avoidance of distractions
Note and monitor behaviors
Modeling by parents
Nutrition Interventions: Referrals




Early Intervention Programs
PT/OT/Speech
Food availability and resources
Registered Dietitian
STRATEGIES
Myth: “He’ll outgrow picky eating.”
Division of Labor in Feeding (Satter)

Parent
 What
to serve
 When to serve

Child
 Whether
to eat
 How much to eat
Get Permission (Klein)




Trust in the feeding relationship
Supports children with complicated sensory
challenges
Promotes enjoyment and confidence
“Adult sets goals – child sets pace”
Sequential Oral Sensory (SOS)
(Toomey)
Transdisciplinary team approach which assess the “whole child”:
organ systems, muscles, development sensory, oral-motor,
learning/behavior, cognition, nutrition and environment.
The SOS Approach focuses on increasing a child’s comfort level
by exploring and learning about the different properties of food
and allows a child to interact with food in a playful, non-stressful
way.
Food Chaining (Fraker)




Imagine a child with difficulty eating
What foods does the child like?
Consider nutritional value of the foods
What similar but more nutrient dense foods do you
want to add first?
Food Chaining Map
Favorite Foods
Alternatives 1
Alternatives 2
Alternatives 3
Alternatives 4
Frozen chicken
nuggets
Homemade
nuggets
Nuggets dipped
in ketchup
Wendy’s chicken Nuggets without
nuggets
breading
Homemade
chicken circles
Nuggets dipped
in hummus
Other “fast
food” nuggets
Other-meat
circles
Nuggets dipped
in gravy
McDonalds
Burger King
Chicken Nuggets chicken Nuggets
Non-chicken
nuggets
Adapted from Roberts, 2012
Food Chaining Map
Favorite Foods
Alternatives 1
Alternatives 2
Alternatives 3
Goldfish
crackers
Annie’s Cheesy
Bunnies
Crackers dipped Veggies dipped
in cheese sauce in cheese sauce
Vegetable
cheese casserole
Alternate flavor
Goldfish
Crackers dipped Veggies dipped
in onion dip
in onion dip
Bread spread
with onion dip
Cheese flavored Crackers dipped Veggies dipped
crackers
in hummus
in hummus
Alternatives 4
Toast with
hummus
Adapted from Roberts, 2012
Food Chaining Map
Favorite Foods
Alternatives 1
Alternatives 2
Alternatives 3
Alternatives 4
Pediasure
Pediasure with
applesauce
Pediasure with
carrots
Pureed carrots
Carrots with
texture
Pediasure with
pureed pears
Pediasure with
peas
Pureed peas
Bread dipped in
peas
Pediasure with
mashed
potatoes
Pediasure with
beets
Pureed beets
Beets mixed
with hummus
Adapted from Roberts, 2012
Changing Diet Journey





Fast Food
Fast Food + Vegetable
Healthy Fast Food
Home Cooking
Organic Foods/Local Foods
Make New Foods Fun

Interact with food in a playful way
 Tolerate
 E.g.,
food in the room
dog’s dish and child’s dish
 Touch,
smell, taste, sound
 “Try-it”
bowl
 “What does it sound like when you chew it?”
 Let child help prepare
 Eat
 With
others
 With imagination
Role of the RD





Identify a picky eater vs. a feeding problem
Document suspected feeding problem
Initiate and inform interdisciplinary feeding team
Assist in developing feeding intervention plan
Educate parents on nutritional needs and basic
feeding strategies
Resources



Pediatric Nutrition Care Manual, Academy of Nutrition and Dietetics, 2012
Fraker C, Fishbein M, Cox S, Walbert L. (2007). Food Chaining: The proven 6-step plan to
stop picky eating, solve feeding problems, and expand your child’s diet. Philadelphia, PA: Da
Capo Press.
Susan L. Roberts, MDiv, OTR/L


Kay Toomey, PhD


www.ellynsatter.com
USDA Guidelines, 10 tips series


www.mealtimenotions.com
Ellyn Satter


http://www.sosapproach-conferences.com/about-us/about-kay-toomey
Marsha Dunn Klein, MEd, OTR/L


http://www.susanlroberts.com/index.html
www.choosemyplate.gov
Gluten and casein free recipes and shopping lists


www.savingdinner.com
www.whattofeedyourkids.com
QUESTIONS??