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
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•
•
•
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
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•
•
•
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:
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•
•
•
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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