nutritional considerations in autism spectrum disorders anne roland lee, msed, rd nutritionist...
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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
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