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Nutritional Status of Children with Autism Spectrum Disorders (ASDs): A

Case–Control Study

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research-article2016
AUT0010.1177/1362361316636976AutismMarí-Bauset et al.

Original Article
Autism

Comparison of nutritional status between 1­–13

© The Author(s) 2016
Reprints and permissions:
children with autism spectrum disorder sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1362361316636976

and typically developing children in the aut.sagepub.com

Mediterranean Region (Valencia, Spain)

Salvador Marí-Bauset1,2, Agustín Llopis-González1,2,3,

Itziar Zazpe4,5, Amelia Marí-Sanchis6 and
Maria Morales Suárez-Varela1,2,3

Abstract
This case-control study investigated nutrient intake, healthy eating index with 10 items on foods and nutrients, on
3-day food diaries and anthropometric measurements in 105 children with autism spectrum disorder and 495 typically
developing children (6–9 years) in Valencia (Spain). Children with autism spectrum disorder were at a higher risk for
underweight, eating more legumes, vegetables, fiber, and some micronutrients (traditional Mediterranean diet) but fewer
dairy and cereal products, and less iodine, sodium, and calcium than their typically developing peers. Differences existed
in total energy intake but healthy eating index and food variety score differences were not significant. Autism spectrum
disorder group failed to meet dietary recommendations for thiamin, riboflavin, vitamin C, or calcium. Risk of inadequate
intake of fiber, vitamin E, and sodium was lower in children with autism spectrum disorder than typically developing
children. Results suggest that (1) risk of inadequate intake of some micronutrients in children with autism spectrum
disorder and (2) cultural patterns and environment may influence food intake and anthropometric characteristics in
autism spectrum disorder. Primary care should include anthropometric and nutritional surveillance in this population
to identify intervention on a case-by-case basis. Future research should explore dietary patterns and anthropometric
characteristics in different autism spectrum disorder populations in other countries, enhancing our understanding of the
disorder’s impact.

Keywords
autism, autism spectrum disorder, feeding assessment, growth, healthy eating index, nutrition

Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental
condition characterized by poor social-emotional reciproc-
ity, impairments in language, and repetitive, stereotyped
behaviors (American Psychiatric Association (APA),
2014). Its prevalence has significantly increased in the last
few decades (Matson and Kozlowski, 2011). In 2010,
overall ASD prevalence in the United States was 14.7 per
1000 (one in 68) children aged 8 years, and the male-to-
female ratio was 5:1 (Centers for Disease Control and
Prevention (CDC), 2014).
Eating is among the most essential of human activities,
necessary not only to sustain life but also to ensure proper
development. In this context, behavioral problems in chil-
dren with ASD at meal times, including food selectivity,
have been observed in many studies over the years.
However, “food selectivity” is used in the literature to refer
to a range of concepts including, for example, food refusal,
1University of Valencia, Spain
2CIBERESP, Institute of Health Carlos III, Spain
3Center for Public Health Research (CSISP-FISABIO), Spain
4University of Navarre, Spain
5CIBERobn, Institute of Health Carlos III, Spain
6Clinical Nutrition and Dietetics Unit, Spain
Corresponding author:
Maria Morales Suárez-Varela, Unit of Public Health and Environmental
Care, Department of Preventive Medicine, University of Valencia, Avd.
Vicente Andres Estellés s/n, Burjassot, 46100 Valencia, Spain.
Email: maria.m.morales@uv.es

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2 Autism
a limited repertoire of accepted foods, high-frequency sin-
gle food intake, excessive intake of a few foods (Bandini
et al., 2010; Hubbard et al., 2014), or selective intake of
certain food categories (such as carbohydrates or fats or
proteins (Attlee et al., 2015). The lack of consensus regard-
ing the definition of selectivity complicates the assessment
and comparison of results from different studies. Atypical
feeding behaviors, adoption of intentional diet restrictions,
and the peculiar lifestyle of individuals with ASD (with not
only different levels of physical activity, but also idiosyn-
cratic social skills and poor social interaction) are factors
that imply risks of both excessive and insufficient intakes
(Twachtman-Reilly et al., 2008). Notably, negative effects
on anthropometric development, such as unhealthy weight
and/or body mass index (BMI), could have adverse conse-
quences due to the incidence of significant comorbid
chronic conditions in the third or fourth decade of life (e.g.
osteoporosis, hypertension, dyslipidemia, cardiovascular
disease, diabetes, and high blood pressure), or even earlier
(sleep apnea, menstrual disorders, or psychosocial disor-
ders). To date, research on growth in children with ASD has
been inadequate with inconsistent, or even contradictory,
results as reported in a systematic review by Marí-Bauset
et al. (2015b).
Macro- and micronutrient intakes of foods have been
compared between children with ASD and their typically
developing (TD) peers. Nearly three decades ago, a nutri-
tional assessment of children with ASD found overall intake
adequacy to be comparable to that in controls (Raiten and
Massaro, 1986), and similar conclusions have been drawn
more recently by other authors (Schmitt et al., 2008;
Zimmer et al., 2012). On the other hand, several authors
(Bandini et al., 2010; Emond et al., 2010; Ho et al., 1997;
Hyman et al., 2012) have reported that intakes of some
nutrients are insufficient: vitamins A, C, B6, B12, D, E, or K, or
folate, phosphorous, fiber, zinc, calcium, or iron). Overall, the
data available are currently insufficient and therefore, there is
no clear consensus on whether nutritional intake is generally
impaired in children with ASD or regarding the potential con-
sequences of this in terms of their development.
We hypothesized that, in general, children with ASD
would (1) have lower anthropometric measurements
(height, weight, and calculated BMI); (2) have lower food
intake of macro- and micronutrients; (3) have lower
healthy eating index (HEI) scores, overall and for food
variety; and (4) meet Spanish Dietary Reference Intakes
(DRIs) less often than TD children. To test these hypothe-
ses, we aimed to characterize the nutritional status of chil-
dren diagnosed with ASD.
Methods
Participants
This case-control study of children with ASD and their TD
peers was carried out in Valencia (eastern area of Spain) in
the second half of 2014. We identified candidate children
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with ASD (n = 272) from the population of all primary-age
children with ASD in the metropolitan area of Valencia
(Spain), attending special schools and primary schools
with inclusion classes for children with this disorder.
Candidate TD children (n = 1364) were identified from the
population of all pupils (n = 15,838) at the inclusive ele-
mentary schools attended by some of the children with
ASD. After visiting all the schools and identifying the
number of classrooms per academic year, we constructed a
stratified randomization table and randomly assigned eli-
gible participants, balanced by school and classroom.
The Ethics Committee of the Dr Peset University
Hospital (Valencia, Spain) approved this study (ref. 46/10).
In the first appointment, before we started the research, we
explained the study to the parents of all the children
involved, including the tests that would be carried out. We
also informed them that the data collected would be kept
confidential in line with the Spanish data protection law,
and we requested informed consent from both parents or
whichever parent accompanied the child at the time of the
visit. If the parents gave consent and the children met the
selection criteria, an appointment was arranged for assess-
ments of the children.
ASD diagnoses were based on results of the Autism
Diagnostic Observation Schedule-Generic (ADOS-G) (Le
Couteur et al., 2008; Lord et al., 2000) and the Autism
Diagnostic Interview-Revised (ADI-R) (Lord et al., 1994)
from the clinical opinion of experienced clinical psychol-
ogists. We only considered diagnosis, and not disorder
severity.
Staff on the local education board indicated that all the
children (with and without ASD) had similar socio-eco-
nomic backgrounds. We cannot rule out the possibility of
there being children with high-functioning ASD among
the controls, but this risk is very low as clinical psycholo-
gists routinely assess all the pupils at the schools from
which TD children were recruited. On the other hand, in
schools where children with ASD attend, behavioral inter-
ventions are implemented by psycho-education specialists
trained in specific techniques to address feeding problems
in children with this disorder.
To be included in the study, both the children with ASD
and the TD children were required to be 6–9 years old (the
Spanish DRIs, the same in this age group for both gen-
ders). The exclusion criteria for both groups were as fol-
lows: use of dietary supplements; any medical condition
(endocrine, metabolic diseases, etc.) that could influence
food intake, and/or physical activity habits; use of drugs
(e.g. stimulants, atypical antipsychotics, tricyclic antide-
pressants, steroids, and mood stabilizers) that could affect
food intake; not attending study interview appointments;
and not completing nutritional records properly.
For both groups, we first excluded families who
declined to participate, then applied the selection criteria
set out above, and subsequently excluded those who we
were unable to contact and/or failed to complete nutri-
tional records (see below). Figure 1 illustrates the flow
Marí-Bauset et al. 3

Figure 1.  Flow diagram of participants through the study (STROBE statement).
Symbol “*” indicates some children met more than one exclusion criterion, and hence the subgroups sum to more than the total.

of children in both groups through the study (in accord-
ance with the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) state-
ment; Vandenbroucke et al., 2007).
Data collection
Examination protocol and measurements
During appointments, the following data were collected by
administering a questionnaire to parents: child’s age, back-
ground of the child’s birth, and child’s medical history. If
they met the selection criteria, the children were included,
and we gave their parents a detailed explanation of how to
assess the food and drink their child consumed by record-
ing estimated portion sizes (measured or assessed accord-
ing to a visual guide provided to improve accuracy) for
each food item. The same training was given to caregivers
in the school dining halls. Parents were asked to hand in
food labels with ingredients, added ingredients, brands, and
recipes for homemade dishes, whenever possible. The
researchers contacted parents by telephone if there were
any incomplete or missing data.
Anthropometric measurements
During the scheduled appointment, the principal investi-
gator himself, a registered dietitian, measured the height

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4 Autism
(in centimeters) and weight (in kilograms) of the child
using standard anthropometric techniques (World Health
Organization, 1996) with a Seca 213® stadiometer and
Seca 813® scale, respectively. Both measurements were
taken in duplicate and the mean values were used to calcu-
late BMI (kg/m2). BMI (kg/m2) was converted into a
z-score with the WHO Anthro software, v.3.2. (Onis et al.,
2007). Based on the percentile ranking, BMI status was
categorized, using National Health and Nutrition
Examination Survey (NHANES) criteria, into the follow-
ing four categories: underweight (⩽5th percentile); healthy
(>5th to <85th percentiles); overweight (⩾85th to <95th
percentiles); and obese (⩾95th percentile) (CDC, 2000).
Dietary assessment
On a form provided, parents were asked to record all the
foods and drinks that their child consumed over a 3-day
period, including one nonworking day (Barrett-Connor,
1991; Institute of Medicine (IOM), 2001). In order to cal-
culate intakes of calories, and macro- and micronutrients
of known public health relevance, researchers entered data
from these food records into an open-source computer pro-
gram, DIAL®. This program, developed by the Department
of Nutrition and Dietetics at the Complutense University
of Madrid, is widely used in Spain and has previously been
validated to assess diets and manage nutritional data. It
includes a list of fortified/enriched foods commonly avail-
able in Spain, to which other items can be added. With this
feature, we included the nutritional composition of pack-
aged foods according to the food labels that parents sub-
mitted. The results were compared with Spanish food
composition tables (Moreiras et al., 2013).
DIAL also calculates the HEI (Kennedy et al., 1995)
from the data supplied. The HEI consists of 10 items: 1–5
concerning the intake of five major food group categories,
cereals, fruit, vegetables, dairy products, and meat; and
6–10 related to nutritional recommendations, total fats,
saturated fats, cholesterol, salt, and food variety. We classi-
fied individuals into three groups: scores >80 points were
considered to indicate a “healthy” diet; 50–80 points indi-
cated “needs to improve”; and ⩽50 points corresponded to
a “poor” diet (Kennedy et al., 1995). Component 10 of the
HEI assesses variety in diet. Higher scores indicated the
child ate more different food items contributing at least half
a serving to any of the food groups: a score of 0 correspond-
ing to ⩽6 foods over the 3 days; and a score of 10 to ⩾16
foods (Kennedy et al., 1995). An intake of ⩾11 foods dur-
ing this period (score = 5) was considered the cut-off, sug-
gesting a high likelihood of adequate micronutrient intake.
Estimating nutrient adequacy/deficiency
DRIs (IOM, 2001, 2003; Murphy and Barr, 2011) include
estimated energy requirements (EERs), recommended die-
tary allowances (RDAs), estimated average requirements
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(EARs), adequate intakes (AIs), tolerable upper intake lev-
els (ULs), and acceptable macronutrient distribution
ranges (AMDRs). We classified children as being at risk of
having inadequate intake for specific nutrients depending
on whether they met DRIs and Spanish nutritional targets
or not (Federación Española de Sociedades de Nutrición,
Alimentación y Dietética (FESNAD), 2010). Comparisons
were made with the DRIs used in the United States (IOM,
2010) to examine any differences. Intake distributions
were adjusted for day-to-day variation using a statistical
modeling approach (National Research Council (NCR),
1985). We used this approach to ensure that data reflected
usual intake. The probability of adequacy for usual nutri-
ent intake was calculated as z-score = (estimated nutrient
intake − EAR)/SD of EAR (Carriquiry, 1999). Applying
these statistical approaches, intake of beneficial nutrients
was considered adequate if covering at least the AMDR for
macronutrients, the EAR (or AI as appropriate) for micro-
nutrients, and the EER for energy. For nutrients presumed
to be detrimental (e.g. total fat, cholesterol, and sodium),
the opposite interpretation was applied, which means the
diet was considered inadequate if the limit was exceeded,
and adequate if the intake was below the limit.
Statistical analysis
For anthropometric measures, we compared the two study
groups in the four BMI categories (underweight, healthy,
overweight, and obese), applying Bonferroni corrections
to control for multiple comparisons. The probabilistic
approach and the EAR cut-point method were used to
assess risk of the inadequacy of nutrient intakes. A
Student’s t-test was run to compare the nutritional intakes
in children with ASD versus TD children. With dichoto-
mous categorical variables, we compared the diet of the
children with ASD with recommended intakes (recom-
mendations met, not at risk vs not met, at risk) using con-
tingency tables, odds ratios (ORs), and the χ2 test (or
Fisher’s exact test, as required) to assess statistical signifi-
cance. The Shapiro–Wilk test was used to confirm assump-
tions of normality, linearity, homoscedasticity, and
independence. We fitted four multivariable-adjusted mod-
els for each dietary variable to control the following poten-
tial sources of bias: (1) age (continuous) and gender (two
categories); (2) the aforementioned variables, plus weight
(continuous) and height (continuous); (3) the aforemen-
tioned variables, plus total energy intake (continuous); and
(4) the aforementioned variables and diet type (two cate-
gories: a gluten-free casein-free diet and a regular diet).
We compared the intakes in the two groups with multi-
ple linear regression by taking nutrients as the dependent
(continuous) variable to generate the corresponding β
regression coefficients and 95% confidence intervals
(CIs), using the TD children as the reference category. We
used logistic regression models to evaluate the inadequacy
of the DRIs or nutritional targets in all the children, again
Marí-Bauset et al. 5

Table 1.  Main characteristics of children with autism spectrum disorder (ASD) and typically developing (TD) children.a

Main Children with ASD (n = 105) TD children (n = 495) p value

characteristics
N (%) Boys n (%) Boys Total Girls Boys

Total Mean Total Mean

(SD) (SD)

Girls Girls
105 (100) 12 (11) 93 (89) 495 (100) 229 (46) 266 (54)
Age (months) 93.68 (14.76) 100.58 (17.47) 93.78 (14.24) 95.46 (13.51) 96.34 (13.24) 94.71 (13.72) 0.22 0.29 0.25
Weight (kg) 28.3 (7.64) 29.19 (6.98) 28.19 (7.75) 29.77 (7.04) 29.90 (7.29) 29.65 (6.83) 0.05 0.74 0.08
Height (cm) 126.62 (9.54) 126.92 (9.30) 126.58 (9.62) 129.10 (9.03) 128.66 (8.76) 129.48 (9.25) 0.012 0.54 0.004
BMI (kg/m2) 17.42 (3.06) 17.88 (2.62) 17.36 (3.12) 17.67 (2.65) 17.84 (2.72) 17.52 (2.60) 0.44 0.96 0.67
BMI z-score 0.69 (1.50) 1.02 (1.23) 0.65 (1.53) 0.82 (1.20) 0.89 (1.19) 0.76 (1.20) 0.37 0.71 0.53
kcal/day 1955 (288) 2056 (345) 1942 (279) 1961 (288) 1975 (292) 1948 (283) 0.86 0.62 0.85
HEI 65.32 (10.79) 65.69 (9.95) 65.27 (10.94) 66.17 (10.22) 67.01 (10.04) 65.45 (10.34) 0.43 0.66 0.89
Food variety 3.72 (2.60) 3.50 (2.71) 3.75 (2.61) 3.53 (2.31) 3.44 (2.29) 3.62 (2.31) 0.45 0.93 0.65
score

BMI: body mass index; HEI: healthy eating index; SD: standard deviation.
aStudent’s t-test was used to compare values for children with ASD and TD children (p < 0.05 being considered significant).

taking the TD children as the reference category. We esti-
mated the crude and multivariate-adjusted ORs with 95%
CIs as follows: failing to comply with these recommenda-
tions (OR > 1). All the p values were two-tailed. Statistical
significance was set at the conventional cut-off (p < 0.05).
Data were entered into an Excel spreadsheet, using
double-data entry to minimize the risk of errors. Data were
then transferred to IBM SPSS Statistics for Windows, ver-
sion 19, for the statistical analysis.
Results
Final samples
A final sample of 105 children with ASD, 93 (89%) boys
and 12 (11%) girls, completed the study. The final sample
size of TD children was 495, 266 (54%) boys and 229
(46%) girls. This ratio of cases and controls (1:4.71) is in
line with Wacholder et al. (1992).
Table 1 compares the crude data on characteristics of
the participants: age, anthropometric parameters, total
energy intake, and the HEI scores (overall and for food
variety) per group, overall and by gender. Analyzing the
anthropometric data, the only statistically significant dif-
ferences were in height: children with ASD overall
(p = 0.012) and boys (p = 0.004) were shorter than their TD
peers. Subsequently, children with ASD were compared to
the controls by BMI category, with TD children as the ref-
erence category, and the analysis indicated an underweight
status in 12 (11%) children with ASD versus 20 (4%) TD
children (OR: 3.03, 95% CI: 1.42–6.45; p < 0.008) overall
and in 10 (11%) boys with ASD versus 13 (5%) TD boys
(OR: 2.39, 95% CI: 1.01–5.69; p < 0.04). Although there
was also a higher risk of being underweight among girls
with ASD (2 girls, 17% vs 7 TD girls, 3%; OR: 4.88, 95%
CI: 0.91–26.33), the sample size was too small to draw
conclusions. In the other BMI categories, no significant
differences were found between the groups.
The HEI scores were similar in the two groups, all the
children’s diets being classified as “needs to improve.”
Then, considering individual scores, we found that only
9% of children with ASD (n = 9) and 6% of TD children
(n = 31) consumed poor diets (χ2 = 0.74; p = 0.39). On com-
ponent 10 of the HEI assessing variety in diet, percentages
of children failing to reach the cut-off for adequate food
variety were similar in the two groups: 64% of children
with ASD (n = 67) and 65% TD children (n = 323) ate ⩽11
foods over 3 days (χ2 = 0.08; p = 0.78); and mean food vari-
ety scores were also similar with means (standard devia-
tion (SD)) of 3.72 (2.60) versus 3.53 (2.31), respectively
(p = 0.45), both of which can be considered limited.
Analysis of nutrients and food groups
Children with ASD had much higher intakes of fiber,
folate, vitamins E and K, and iron, and a lower intake of
calcium than controls. The crude mean nutrient intakes in
both groups are reported in detail in Supplementary Online
Table 1.
Table 2 summarizes comparisons between the groups
adjusted for age, gender, height, weight, total energy, and
diet type (on gluten-free casein-free diet or not). Children
with ASD ate considerably fewer cereals and dairy prod-
ucts, but more legumes and vegetables than TD children.
After adjustments with linear regression, in addition to
fiber, folate, vitamins E and K, and iron, their intakes of
vitamin B6, zinc, magnesium, and potassium were found to
be significantly higher, while intakes of calcium, iodine,

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 6

Table 2.  Linear multiple regression analysis.a

Crude Multivariable 1 Multivariable 2 Multivariable 3 Multivariable 4

  Coeff. ß 95% CI Coeff. ß 95% CI Coeff. ß 95% CI Coeff. ß 95% CI Coeff. ß 95% CI
Cereals (g) −21.02 −32.57 to −9.48** −22.75 −33.96 to −11.55** −19.43 −30.25 to −8.61** −18.98 −28.65 to −9.31** −20.01 −30.45, −9.58**
Legumes (g) 38.03 23.29–52.77** 39.36 24.02–54.69** 39.34 23.9–54.77** 39.28 23.84–54.72** 21.17 4.98, 37.36*
Vegetables (g) 23.96 7.6–40.33* 28.29 11.61–44.97** 31.42 14.87–47.97** 31.47 14.92–48.02** 22.52 4.77, 40.28*
Dairy products (g) −82.86 −118.61 to −47.12** −95.76 −132.7 to −58.83** −92.92 −129.85 to −55.99** −92.30 −128.66 to −55.95** −40.84 −78.46, −3.22*
Fiber 1.41 0.48–2.35* 1.51 0.59–2.43* 1.80 0.91–2.7** 1.83 0.99–2.67** 1.20 0.3, 2.09*
Vit. B6 (mg) 0.12 −0.02 to 0.26 0.15 0.01–0.29* 0.18 0.03–0.32* 0.18 0.04–0.32* 0.16 0.01, 0.31*
Folate (mcg) 18.49 2.9–34.09* 21.21 5.64–36.79* 25.51 10.2–40.82 25.87 11.06–40.68** 21.63 5.68, 37.59*
Vit. E (mg) 1.08 0.41–1.74* 1.04 0.36–1.72* 1.21 0.54–1.88** 1.23 0.59–1.87** 1.00 0.31, 1.68*
Vit. K (mcg) 23.45 12.66–34.24** 24.49 13.44–35.54** 26.49 15.48–37.49** 26.68 15.87–37.49** 23.48 11.83, 35.13**
Calcium (mg) −88.93 −140.93 to −36.93** −111.12 −163.83 to −58.42** −101.18 −153 to −49.36** −99.65 −148.81 to −50.49** −29.16 −79.97, −21.65*
Iron (mg) 1.33 0.6–2.07** 1.38 0.65–2.1** 1.61 0.9–2.31** 1.63 0.97–2.29** 1.10 0.39, 1.8*
Iodine (mcg) −5.33 −10.41 to 0.25 −6.46 −11.58 to −1.34* −5.09 −10.11 to −0.08* −4.98 −9.82 to −0.13* −3.26 −8.47, −0.19*
Zinc (mg) 0.48 −0.03 to 0.93 0.40 −0.04 to 0.85 0.53 0.1–0.96* 0.55 0.16–0.94* 0.49 0.07, 0.91*
Magnesium (mg) 13.07 −2.14 to 23.99 12.90 2.13–23.66* 16.33 5.98–26.68* 16.73 7.32–26.14* 10.46 0.4, 20.52*
Sodium (mg) −148.75 −275.95 to −21.55* −171.60 −297.47 to −45.73* −129.06 −248.79 to −9.34* −124.04 −230.82 to −17.26* −61.94 −176.38, −52.51*
Potassium (mg) 116.88 −7.68 to 226.08 106.58 3.03–216.18* 143.87 38.93–248.8* 147.42 49.68–245.16* 150.94 45.48, 256.41*

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ASD: autism spectrum disorder; TD: typically developing; Vit.: vitamin; CIs: confidence intervals.
Beta (β) coefficients and 95% CIs are interpreted as the mean difference in intake between children with ASD and TD children.
Multivariable 1: adjusted for age (continuous) and sex.
Multivariable 2: also adjusted for weight (continuous) and height (continuous).
Multivariable 3: also adjusted for total energy intake (continuous).
Multivariable 4: also adjusted for diet type (gluten-free casein-free vs regular diet).
aIntake of TD children is used as the reference (zero values).

Level of significance *p < 0.05, **p < 0.001.

Autism
Marí-Bauset et al. 7

and sodium were significantly lower than those in TD chil-

1.41–147.43*
1.04–164.13*

1.09–46.26*
1.69–6.31**
dren. Exploring nutritional inadequacy in the two groups

0.09–0.82*

1.12–6.03*
0.25–0.79*

0.27–0.90*
of children compared to DRIs, we found the following: (1)

95% CI
High percentages failing to meet recommendations were

Multivariable 4
common in both groups with low intakes of carbohydrate
(91% in children with ASD vs 87.47% in the controls),

0.28
4.25
13.08
2.60
0.43
3.26
7.09
0.49
vitamin D (82.86% vs 84.24%, respectively), iodine

OR.
(62.86% vs 65.66%, respectively), and excessive fat
intakes (71% vs 69.49%, respectively), and the differences
were not significant. (2) The amount of fluoride consumed

0.84–108.36

3.11–9.99**
0.44–91.72
0.07–0.52*

0.23–0.77*

0.28–0.86*
0.79–4.06

0.44–10.8
was insufficient in all the children (in both groups). (3)

95% CI
The percentage of children consuming less than the recom-

Multivariable 3
mended amount of fiber and vitamin E intake was higher
in TD children than their peers with ASD. And finally, (4)
deficient riboflavin, vitamin A, and calcium intakes were

0.20
6.37
9.52
1.79
0.42
5.57
2.18
0.48
OR.
more common in children with ASD than their TD peers,
while a sodium intake lower than the DRIs was more fre-
quent in the ASD than the TD group. For all the other

0.48–91.31
0.91–84.42
0.09–0.59*

0.24–0.78*

0.33–0.91*
2.95–9.2**
0.78–3.97

0.4–8.48
nutrients, no statistically significant differences were

95% CI
found between the groups when comparing intakes to
DRIs, and the distribution of intakes was similar. The

Multivariable 2
results are listed in detail in Supplementary Online Table
2. When these comparisons were made with the DRIs for
the United States (IOM, 2010), we observed similar inad-

0.23
6.62
8.77
1.76
0.44
5.21
1.84
0.55
OR.
equate intake levels, except for carbohydrates (AMDR in
Spain 50–55 vs 45–65% in United States) and iodine
(EAR: 120 vs 65 mcg, respectively) (data not shown).
1.31–107.63*
0.58–101.84

3–9.25**
Table 3 summarizes the risk of inadequate intakes in
0.11–0.68*

0.29–0.91*

0.30–0.79*
0.89–4.44

0.48–9.73
children with ASD using the logistic regression analysis
95% CI

with TD children taken as the reference category. The ORs

DRIs: dietary reference intakes; TD: typically developing; Vit.: vitamin; CIs: confidence intervals.
in the adjusted model indicate a higher risk of failing to
Multivariable 1

meet recommendations for certain nutrients in children

with ASD: thiamin (4.25-fold), riboflavin (13.08-fold),
vitamin C (2.60-fold), iron (7.09-fold), and calcium (3.26-

Multivariable 4: also adjusted for diet type (gluten-free casein-free vs regular diet).
0.27
7.67
11.86
1.99
0.52
5.27
2.17
0.48
OR.

fold). On the other hand, the risk of inadequate intakes was

Multivariable 2: also adjusted for weight (continuous) and height (continuous).
higher in TD children for fiber, vitamin E, and sodium.
We repeated the main analyses using the EAR cut-point
2.16–176.88*

method and the results were very similar (data not shown).
2.29–6.15**
0.21–26.38
0.13–0.68*

0.31–0.91*

0.34–0.83*

Multivariable 3: also adjusted for total energy intake (continuous).

0.42–5.97
0.72–3.2
95% CI

Risk of failing to meet DRIs or nutritional targets in children.

Discussion
aIntake of TD children is taken as the reference (1 Ref.).
Multivariable 1: adjusted for age (continuous) and sex.

Our first hypothesis was that children with ASD would

Crude

have significantly lower anthropometric values, and this is

19.56
0.30
2.37

1.52
0.53
3.75
1.59
0.52
OR.

confirmed by our results (ORs adjusted for the BMI cate-

Table 3.  Logistic regression analysis.a

Level of significance *p < 0.05, **p < 0.001.

gories showed high risks of being underweight in all chil-

dren with ASD and boys with ASD). Furthermore, children
DRIs/targets

with ASD overall and boys (this does not occur with girls)
were shorter than TD children. There is no consensus
⩽2400
6–9 y.

among previous research comparing the anthropometric

800
0.8
1.2
25

55
8

values of children with ASD and TD children (e.g. Attlee

et al., 2015; Bauset et al., 2013; Curtin et al., 2010; Egan
Riboflavin (mg)

et al., 2013; Emond et al., 2010; Evans et al., 2012; Ho et al.,

Calcium (mg)
Thiamin (mg)

Sodium (mg)
Vit. C (mg)

1997; Zimmer et al., 2012). Likewise, Hill et al. (2015)

Vit. E (mg)

Iron (mg)
Fiber (g)

found that prevalence of overweight and obesity was sig-

nificantly higher among young children (2–5 years of age)
 

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8 Autism
and adolescents (12–17 years of age) with ASD compared
with the matched controls. However, for ages 6–11 years,
no prevalence differences were found. In addition, Hyman
et al. (2012) reported in their study that children aged
2–5 years with ASD had more overweight and obesity, and
children aged 6–11 years had more underweight than the
NHANES-matched cohort. These results are consistent
with studies previously carried out in Spain (Bauset et al.,
2013; Marí-Bauset et al., 2015a), and with our findings in
the 6–9 years age group in this study. These differences
observed in terms of the age group studied could be
explained due to the fact that children with ASD and aged
2–5 years spend more time carrying out therapeutic activi-
ties, where snacks can be used to reinforce participation,
which may favor unhealthy weight gain. Also, they may
have fewer opportunities for or interest in active playing
than their matched TD peers, a circumstance which can
favor unhealthy weight gain. However, the exact reason
why the weight would be unhealthy among children with
ASD is not clear. Among schoolchildren of the age studied
herein, growth is highly sensitive to the balance between
energy intake and total energy expenditure (Bölte et al.,
2002; Ho et al., 1997). However, in our sample, the energy
intake estimates in children with ASD and TD children
were similar. Apart from physical activity, abnormal
behaviors can also result in higher levels of stress. Also,
other mechanisms that can cause development in these
children with ASD to differ from that in TD children
include, among others, medical comorbidities (e.g. gastro-
intestinal diseases), or even neuroendocrine or genetic fac-
tors (Newschaffer et al., 2007). Likewise, ASD and TD
groups could present different patterns of growth through-
out timelife (Hill et al., 2015). In any case, although BMI
is an important indicator for healthy weight, it is not neces-
sarily a good indicator of nutrient status.
Second, we hypothesized that children with ASDs
would have lower macro- and micronutrient intakes from
food than TD children, and we found this to be true only
for intakes of dairy products, cereals, calcium, iodine, and
sodium. In contrast, the intakes of children with ASD were
significantly higher for legumes, vegetables, fiber, folate,
vitamins B6, E, and K, iron, zinc, magnesium, and potas-
sium. These findings are in line with the traditional
Mediterranean diet in our geographical region (Valencia,
Spain), and different from the so-called Western diet. The
review of the nutritional results of the cited articles quickly
revealed that the existing body of literature is best described
as highly limited in terms of research quality. Only three
nutritional studies (Hediger et al., 2008; Herndon et al.,
2009; Hyman et al., 2012) were of sufficient experimental
rigor, due to the study design and size, so as to be classified
as high-quality evidence. According to a recent systematic
review (Marí-Bauset et al., 2015b), despite the fact that the
studies in this area have suffered from methodological
weaknesses (the lack of control groups, unclear selection
Downloaded from aut.sagepub.com at Universidad de Valencia on May 2, 2016
criteria, analysis of single individuals or small or age-
heterogeneous samples, among others), the nutritional
assessment has indicated limited food variety in the ASD
population and has not confirmed significant differences
on macronutrients; yet it has shown an inadequate intake
of certain types of micronutrients in children with ASD
with respect to DRIs or controls. These findings are con-
sistent with those obtained in our study. Indeed, nutritional
requirements in these children in terms of energy and
macronutrients seem to be satisfied despite the rates of
food selectivity and dietary restrictions. However, all the
previously cited studies, as well as our study, found that a
wide range of nutritional inadequacies—both excessive
and insufficient intake of micronutrients—existed in chil-
dren with ASD.
Previous studies assessing nutritional factors among
children with ASD have reported mixed results regarding
nutritional deficiencies in this population (e.g. Alpert,
2007; Keen, 2008; Kranz et al., 2006; Schreck et al., 2004).
Notably, a body of previous research conducted among
individuals with selective eating patterns like those
observed in ASD has shown inadequate intakes of low-
energy foods, such as fruit and vegetables (Dovey et al.,
2008; Dubois et al., 2007; Emond et al., 2010; Evans et al.,
2012; Kranz et al., 2006), high-fiber foods, and lean pro-
tein-rich foods (Dovey et al., 2008; Dubois et al., 2007;
Evans et al., 2012), trends which contrast with the charac-
teristics of a Mediterranean diet.
On the other hand, studies comparing the nutrient
intake of children with ASD with that of TD children have
often minimized differences in nutrient intake between
these groups. For instance, Shearer et al. (1982) used
3-day diet record, as we did, and observed lower calcium
and riboflavin intake in children with ASD than TD con-
trols, yet concluded that overall, the nutrient intake of
children with ASD was adequate and typical of well-fed
American children. A classic study (Raiten and Massaro,
1986) indicated that individuals with ASD presented sig-
nificantly higher intakes of total energy, proteins, and car-
bohydrates, but not of fat; however, the authors concluded
that despite food selectivity, the overall adequacy of the
diets consumed was similar for both groups. Other
researchers (Hyman et al., 2012; Shearer et al., 1982)
have reported significantly lower total energy intakes.
More recent studies (Emond et al., 2010; Johnson et al.,
2008; Lockner et al., 2008) have not observed major dif-
ferences in nutritional intake (total energy, fats, carbohy-
drates, proteins) compared to TD children, although
children with ASD display more behavioral problems at
meal times (Johnson et al., 2008).
Regarding specific micronutrients, children with ASD
have been observed to have much higher intakes for niacin,
thiamin, and riboflavin (Raiten and Massaro, 1986); sev-
eral studies have reported low vitamin intakes, for vitamin
A (Hyman et al., 2012; Raiten and Massaro, 1986; Shearer
Marí-Bauset et al. 9
et al., 1982), vitamin C (Emond et al., 2010; Hyman et al.,
2012; Raiten and Massaro, 1986; Shearer et al., 1982), vita-
min D (Emond et al., 2010), and/or riboflavin (Hyman
et al., 2012; Shearer et al., 1982). Significantly higher
intakes for calcium, phosphorus, and iron (Raiten and
Massaro, 1986) have also been indicated. On the other
hand, other research studies (Hyman et al., 2012; Shearer
et al., 1982) found significantly lower intakes of calcium,
zinc, and phosphorus, but concluded that children with
ASD eat similar amounts of nutrients to controls.
Our third hypothesis was that the overall HEI scores
and for food variety for children with ASD would be sig-
nificantly lower than those of TD children. Yet despite
inadequate intakes of one or more macro- or micronutri-
ents, in our sample, differences between groups were not
significant for the HEI. The HEI scores classified the diets
of children with ASD and TD children as “needs to be
improved.” This quantitative result is comparable to previ-
ous findings (Hyman et al., 2012; Johnson et al., 2008;
Lockner et al., 2008; Raiten and Massaro, 1986), although
these earlier studies did not explicitly report HEI values.
To our knowledge, only two other studies have investi-
gated the HEI in ASD. Graf-Myles et al. (2013) found that
the children with ASD who did not follow a restricted diet
obtained significantly lower HEI scores than those on a
restricted diet and TD children, while Johnson et al. (2014)
suggested that as feeding and mealtime behaviors are
worse in children with ASD, the quality of their diet would
also be worse.
The scores of component 10 of HEI (“variety in diet”)
were not significantly different in the two groups. This
finding may be explained by the fact that parents and car-
egivers whose offspring have been diagnosed with ASD
pay particular attention to diet and nutrition of their chil-
dren and this may compensate to some degree for difficult
eating behaviors. In any case, our data showed limited
food variety in children with ASD.
Finally, our fourth hypothesis proposed that children
with ASD would meet Spanish daily recommended intakes
less often than TD children. Significant differences were
only found for certain nutrients: (1) a high percentage of
children in both groups exceeded the DRIs for sodium, but
a sodium intake in line with recommendations (i.e. lower
than the DRIs) was more common in the children with ASD;
and (2) despite intakes being adequate in most children in
both groups, the percentage of children with ASD who met
the guidelines was higher for vitamin E, but lower for biotin,
riboflavin, vitamin A, and calcium than in TD children.
Furthermore, the majority of children in both groups failed
to meet the recommendations for carbohydrates, with lower
intakes than DRIs, and the same could be said for lipids,
with excessive intakes, but differences were not significant.
Some previous research has observed low protein
intakes (Zimmer et al., 2012), while other studies have
reported imbalanced macronutrients with higher intakes of
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lipids (Cornish, 1998; Souza et al., 2012) and proteins
(Cornish, 1998; Levy et al., 2007; Sadowska and Cierebiej,
2011; Souza et al., 2012) than the recommended. In addi-
tion, some authors found the intakes of calories, carbohy-
drates, and fats to be adequate in most children with ASD
(Levy et al., 2007), whereas others observed intakes of
calories and proteins to be adequate in the vast majority of
children with ASD, but fat intake to be lower than DRIs in
these children (Xia et al., 2010). On the other hand, several
studies (Herndon et al., 2009; Hyman et al., 2012; Kranz
et al., 2006; Sadowska and Cierebiej, 2011) have found
low intakes of fiber compared to DRIs, consistent with our
results, and many previous studies (Cornish, 1998; Hediger
et al., 2008; Herndon et al., 2009; Hyman et al., 2012;
Lindsay et al., 2006; Moore et al., 2004; Neumeyer et al.,
2013; Sadowska and Cierebiej, 2011; Zimmer et al., 2012)
have obtained similar results to ours regarding vitamin D,
intakes being below nutritional recommendations.
Regarding vitamins, we found a smaller proportion of
children with ASD than their peers failed to meet vitamin
E intake recommendations. However, other studies
(Herndon et al., 2009; Suitor and Gleason, 2002) have
reported children with ASD to have lower vitamin E
intakes, failing to meet nutritional recommendations. On
the other hand, some authors have observed that niacin,
vitamin B1, and vitamin B2 sufficed for most children with
ASD (Xia et al., 2010), and others that a high proportion of
children with ASD presented lower than the recommended
intakes of riboflavin (Shearer et al., 1982), niacin (Cornish,
1998), or pantothenic acid (Lindsay et al., 2006). Low
intakes of vitamin B12 (Zimmer et al., 2012), vitamin B6
(Cornish, 1998; Xia et al., 2010), and folate (Cornish,
1998) have also been reported. Furthermore, intakes have
been reported to be lower than DRIs for vitamin A
(Sadowska and Cierebiej, 2011; Xia et al., 2010), vitamin
C (Cornish, 1998; Xia et al., 2010), and vitamin K (Lindsay
et al., 2006) in some individuals, although growth rates do
not seem to be affected (Xia et al., 2010).
With regard to minerals, several studies have indicated
similar results for children with ASD to those reported
herein, with calcium intakes below DRIs (Bandini et al.,
2010; Cornish, 1998; Hediger et al., 2008; Herndon et al.,
2009; Ho et al., 1997; Johnson et al., 2008; Neumeyer
et al., 2013; Suitor and Gleason, 2002). Numerous studies
(Bilgiç et al., 2010; Cornish, 1998; Dosman et al., 2007;
Herndon et al., 2009; Ho et al., 1997; Johnson et al., 2008;
Latif et al., 2002; Reynolds et al., 2012; Sadowska and
Cierebiej, 2011; Shearer et al., 1982; Xia et al., 2010) have
reported that children with ASD do not meet DRIs for iron,
while other data (Sadowska and Cierebiej, 2011; Shearer
et al., 1982; Xia et al., 2010), including those of this study,
are inconsistent with these earlier findings. Several authors
observed mixed results for magnesium: a high intake
(Sadowska and Cierebiej, 2011; Zimmer et al., 2012), AI
in most children with ASD (Xia et al., 2010), or low daily
10 Autism
intake (Levy et al., 2007), while intakes of zinc were lower
than DRIs (Xia et al., 2010; Zimmer et al., 2012). Others
(Sadowska and Cierebiej, 2011) have published results
regarding intakes of sodium and phosphorus, but the val-
ues did not differ significantly from those of the reference
population.
The general picture remains unclear. Some authors
have concluded that the mean intakes for macronutrients
and micronutrients tend to exceed DRIs (Lindsay et al.,
2006) while others have indicated that the majority of chil-
dren with ASD do not generally meet recommended nutri-
ent intakes (Ho et al., 1997).
It could be argued that DRIs should differ for children
with ASD. However, despite there being biological differ-
ences between the groups, there is still no basis to date to
assert that they have different metabolic requirements.
Furthermore, the mixed results available should be inter-
preted cautiously. Comparisons can be hindered by the fol-
lowing: a lack of standard criteria for nutritional tables
across countries; variations in age groups for which rec-
ommendations are defined; authors using distinct cut-off
values to define “inadequacy”; and recommended levels
not specifying the availability and consumption of forti-
fied foods. All these aspects may lead to studies producing
results that are not directly comparable, and this likely
underlies the seemingly inconsistent results.
Study limitations
Our results show a probability of inadequacy, but do not
determine whether the diet of the ASD group is adequate
or not. Real nutritional deficiency should be confirmed by
specific biomarkers of nutrient intake. In our sample of
children with ASD, there were considerably more boys
than girls, reflecting the gender imbalance in the preva-
lence of the disorder. Although this imbalance was not pre-
sent in the TD sample, the Spanish dietary recommendations
for the age group studied (6–9 years) are the same for boys
and girls, and this homogeneity in the age group, as well as
multivariable-adjusted models, reduces the impact of this
potential source of bias.
In addition, results obtained using two different meth-
ods (the probabilistic approach and the EAR cut-point
approach) to estimate nutrient intake adequacy were very
similar. The use of the latter approach as a reference for
estimating nutritional adequacy compared with the DRIs
value avoids overestimation of the prevalence of dietary
inadequacy. Although the sample sizes were relatively
small in comparison with several studies previously car-
ried out by researchers in other countries and may not be
fully representative of the population of the country, we
believe that our study offers strong internal validity given
the low attrition rate. We are confident about the good
quality of the self-reported information used for the nutri-
tional assessment. Parents were very interested in the study
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from the outset and were extensively trained and supported
in the completion of the food records. All this can compen-
sate for the limitations that the selection of the sample may
impose or for external validity generalization. We should
also point out that data for the cases and controls that were
compared had been adjusted for age, sex, weight, height,
and total energy intake as potential confounders, as well as
all children having a similar place of residence and socio-
economic status, and being followed up over the same
time period. We believe that these factors may help to
compensate for limitations in generalizability and external
validity associated with participant selection. Furthermore,
our study was also substantially larger than any previous
research work of this type conducted in Spain. Finally, it
could be that DRIs should be different for children with
ASD, although for the moment, no alternative recommen-
dations have been proposed.
Conclusion
Recommendations and implications for practice
Although many children with ASD in our sample did not
eat the recommended intakes of certain nutrients, this is
generally the case for the Spanish child population (Varela-
Moreiras et al., 2010). So far, the data available remain
insufficient to reach a clear consensus as to whether nutri-
tional intake is generally impaired in children with ASD
and regarding its potential consequences for their develop-
ment. However, given some evidence that certain children
with ASD do not eat a balanced diet, anthropometric moni-
toring is important and it is necessary to investigate the
range and severity of risk of deficiencies or excesses with
longitudinal studies to better manage their diet in order to
minimize the possible risk of them developing comorbid
chronic conditions.
More research is needed to corroborate our findings.
Given stark differences between our findings and reports
from other parts of the world, future research should con-
sider the role of environment and cultural dietary patterns
in food selectivity and food intake in children with ASD
and attempt to clarify the relationships between ASD-
related symptoms, anthropometric values, eating patterns,
and health status. Other areas for future work include
characterizing the various behavioral ASD phenotypes by
considering more detailed diagnoses and standardizing
protocols to assess nutritional problems. HEI results can
be used to guide clinical and research activities in this
area although more data are needed to validate food vari-
ety as an indicator of the risk of deficient or excessive
nutrient intakes. Our anthropometric and nutritional
results in children with ASD suggest that these variables
may be useful for stratifying this study population for
clinical and genetic studies, and for developing new ave-
nues of research in the epigenetics field, particularly in
Marí-Bauset et al. 11
nutrigenomics and nutrigenetics. Finally, the main impli-
cations of this study for practice are that clinical recom-
mendations should be made on a case-by-case basis after
considering together dietary assessment, anthropometric,
and laboratory results.
Acknowledgements
The authors wish to thank the children who participated and their
parents for collaborating with the study. The authors are also
grateful for support from colleagues at the Dr Peset University
Hospital (Valencia, Spain). No external funding was received for
this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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