“TO STUDY THE CORRELATION OF DIET AND

NUTRITION IN CHILDREN WITH AUTISM

SPECTRUM DISORDER (3 TO 6 YEARS OF AGE)”

A Dissertation submitted to

Vivekananda Global University

In partial fulfilment of the requirements for the Degree of

MASTERS IN OCCUPATIONAL THERAPY (PEDIATRICS)

Under the Guidance of:

Scholar:
Dr. Deepika Kachhawa Ruby Gupta
Assistant Professor

Faculty of Allied Healthcare Sciences

Vivekananda Global University

1
 Jaipur, Rajasthan

A WORD OF VENERATION

It is my pleasant duty to place on record my sincere gratitude to esteemed head of

institution Dr. LALIT K. PANWAR, Chairperson of Vivekananda global

university for his encouragement, care, support, affection and knowledge that he

showered on me during his tenure. He has a greater clarity of vision and immense

dynamism.

His amiable personality and genuine approach have made a lasting impression on

me and it would be a pleasure being a student under. It is my duty to place on

record my sincere gratitude to his stimulating guidance.

NAME OF SCHOLAR
RUBY GUPTA

2
 CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “TO STUDY THE CORRELATION OF DIET

AND NUTRITION IN CHILDREN WITH AUTISTISM SPECTRUM DISORDER (3 TO 6

YEAR AGE)” is an original piece of research work carried out by RUBY GUPTA under the

supervision of Dr. DEEPIKA KACHHAWA and this work is part or full has not been

submitted to any other university.

PLACE: JAIPUR NAME OF GUIDE

DATE: Dr. Deepika Kachhawa
Assistant Professor
AHCS, VGU

3
 ENDROSEMENT BY THE HEAD OF INSTITUTE

This is to certify that the dissertation entitled “TO STUDY THE CORRELATION OF DIET

AMD NUTRITION IN CHILDREN WITH AUTISM SPECTRUM DISORDER (3 TO 6

YEARS OF AGE)” is an original piece of research work carried out by RUBY GUPTA

under the supervision of DR. BHUPESH GOYAL, HOD, VGU, JAIPUR and this work is

part or full has not been submitted to any other university.

PLACE: JAIPUR DR. BHUPESH GOYAL

DATE: HOD
AHCS, VGU

4
 CERTIFICATE BY THE STUDENT

This is to certify that the dissertation entitled “TO STUDY THE CORRELATION OF DIET

AND NUTRITION IN CHILDREN WITH AUTISM SPECTRUM DISORDER (3 TO 6

YEARS OF AGE)” is an original piece of research work carried out by me, under the

supervision of Dr. DEEPIKA KACHHAWA and this in part or full has not been submitted to

any other university.

NAME OF THE SCHOLAR

RUBY GUPTA

5
 CERTIFICATE BY THE EXAMINER

This is to certify that the dissertation entitled “TO STUDY THE CORRELATION OF DIET

AND NUTRITION IN CHILDREN WITH AUTISM SPECTRUM DISORDER (3 TO 6

YEARS OF AGE)” is a genuine research work of RUBY GUPTA.

PLACE: JAIPUR
DATE:

INTERNAL EXAMINER: EXTERNAL EXAMINER:

6
 ACKNOWLEDGEMENT

I feel pleasure to acknowledge a sense of deep indebtedness to my Supervisor DR.

BHUPESH GOYAL, Professor, Dept. of Allied Healthcare Sciences, Vivekananda Global
University, Jaipur in whom I found the inspiration of an ideal hard-working teacher. The
difficult task of this dissertation could not have been accomplished without the timely help,
learned guidance and painstaking supervision provided to me. No words can express my
deep respect and sincere gratitude to them.

I am very thankful to DR. DEEPIKA KACHHAWA, Associate Professor, Dept. of Allied

Healthcare Sciences, Vivekananda Global University, Jaipur for her kind support and
valuable inspiration during my whole work of dissertation.

I am pleased to acknowledge the Dean, Faculty of Medical Sciences, Prof. (Dr.) BALDEV
SINGH, Vivekananda Global University, Jaipur, who gave me this opportunity with
important guidelines regarding various points to be taken during the whole of my work.

I am grateful to the faculty members of Department of Allied Healthcare Sciences for the
wonderful insights provided during lecture classes. I wish to thank my friends who have
directly or indirectly contributed in the completion of my work.

Finally, I would like to express my heartfelt thanks to my parents and friends for their
generous support and encouragement.

I hope that the reader will find my work interesting, and that my contributions in this
dissertation can play a part for the further research.

7
 RUBY GUPTA
22MED30T008

TABLE OF CONTENT

S.NO. CHAPTER PAGE NO.

1. INTRODUCTION 9

2. AIMS AND OBJECTIVE 30

3. REVIEW OF LITERATURE 31

4. MATERIAL AND METHODS 44

5. RESULTS 46

6. DISCUSSION 50

7. CONCLUSION 57

8. REFERENCES 62

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 INTRODUCTION

Nutrition is the basic and functional unit for the maintenance of good health. Basic and

applied research on the interrelations between nutrition and non-communicable diseases,

nutrient composition, and nutrition monitoring represents the base ground support for healthy

populations and robust economies.

Nutrition is vital, not only for the growth and development of humans but also in the

prevention and treatment of any disease.

Plant and animal foods and their components we get from them are the primary vehicles that

provide nourishment to human beings.

The attainment of good nutrition depends on the entire food supply, the person taking

throught out his life.

Better nutrition helps to improve child and maternal health, develop stronger immune

systems, maintain safer pregnancy and childbirth, lower the risk of non-communicable

diseases (such as diabetes and cardiovascular disease), and longevity.

Healthy children learn better. People with adequate nutrition are more productive and can

create opportunities for themselves to gradually break the cycles of poverty and hunger.

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The developmental, economic, social, and medical impacts of the global burden of

malnutrition are serious and lasting for individuals and their families, for communities and

for countries.

Nutrients are the substances that provide energy and physical components to the humans,

allowing it to survive, grow, and reproduce. Nutrients can be the basic elements or the

complex macromolecules. Approximately 30 elements that are found in organic matter,

nitrogen, carbon, and phosphorus being the most important elements. Macronutrients are the

primary substances that are required by an individual, and micronutrients are the substances

that are required by an individual in trace amounts. Organic micronutrients are classified

as vitamins, and inorganic micronutrients are classified as minerals.

Nutrients are absorbed by the various cells of our body and used in metabolic biochemical

reactions. These include fuelling reactions that create precursor metabolites and energy,

biosynthetic reactions that convert precursor metabolites into building block

molecules, polymerizations that combine these molecules into macromolecule polymers, and

assembly reactions that use all these polymers to construct cellular structures.

Nutrient deficiencies also known as malnutrition, occurs when an individual does not have

adequate amount of nutrients in his body, according to his/her body requirement. This may be

caused by suddenly losing nutrients or the inability to absorb proper nutrients. Not only

malnutrition is the result from a lack of necessary nutrients, but it can also be a result from

10
other underlying illnesses and health conditions. When this occurs, an individual will adapt

reducing in energy consumption and expenditure to the prolong use of stored nutrients. It will

use stored energy reserves until they are depleted, and then it will break down its own body

mass for additional energy.

Malnutrition, in every term, presents significant threats to human health. Today the world

faces a double burden of malnutrition that includes both under nutrition and overweight,

especially in low- and middle-income countries. There are multiple forms of malnutrition,

including under nutrition (wasting or stunting), inadequate vitamins or minerals, overweight,

obesity, and resulting diet-related non-communicable diseases.

Human nutrition deals with the provision of essential nutrients in food that are necessary to

support human life and good health. Poor nutrition is a chronic problem often linked to

poverty, food security, or a poor understanding of nutritional requirements. Malnutrition and

its consequences are large contributors to deaths, physical deformities,

and disabilities worldwide. Good nutrition is necessary for children to grow physically and

mentally, and for normal human biological development.

Nutrients can be grouped as either macronutrients or micronutrients .

The seven major classes of nutrients are :

carbohydrates, fats, fibre, minerals, proteins, vitamins, and water.

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Carbohydrates, fats, and proteins are macronutrients, and provide energy. Water and fibre are

macronutrients, but do not provide energy. The micronutrients are minerals and vitamins.

The macronutrients (excluding fibre and water) provide structural material (amino acids from

which proteins are built, and lipids from which cell membranes and some signalling

molecules are built), and energy.

Vitamins, minerals, fibre, and water do not provide energy, but are required for other reasons.

A third class of dietary material, fibre (i.e., no digestible material such as cellulose), seems

also to be required, for both mechanical and biochemical reasons, though the exact reasons

remain unclear.

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DIAGRAMMATIC REPRESENTATION OF MAJOR CLASSES OF NUTRIENTS AND

THEIR FUNCTION IN THE BODY

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For all age groups, males on average need to consume higher amounts of macronutrients

than females. In general, intakes increase with age until the second or third decade of life.

Autism Spectrum Disorder (ASD) is a multicomplex disorder characterized by an umbrella of

specific issues in the areas of social communication, restricted interests, and repetitive

behaviours. The incidence of ASD is worldwide, and recent epidemiological data estimated it

to be higher than 1/100 .Promising evidence-based interventions for core symptoms in

children and adolescent have been developed in recent years .However, in addition to the core

symptoms, ASD may have strong associations with other disorders and/or be associated with

a plethora of behaviours and symptoms, such as those related to food selectivity and the

consequent inadequate dietary intake.

Although some types of eating disturbances, such as food refusal, are also frequent in the

general paediatric population, their prevalence appears to be significantly higher in ASD

children, with rates ranging from 51% to 89%.

There is evidence that children with ASD consume fewer fruits and vegetables and have a

lower intake of calcium and protein, compared to their typically developing peers. Moreover,

children with ASD prefer foods with high carbohydrate, content such as white bread, pizza,

cakes, cookies, ice-cream, or “fatty” foods .These foods are generally sweet, while on the

contrary, bitter or sour tastes are more frequently rejected. This preference can cause a rise of

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blood glucose and triglycerides, resulting in overweight status and obesity , or endocrine

disturbances such as diabetes ,not to mention dental caries, since correct and constant oral

hygiene is not always possible .Additionally, children with ASD often have an inadequate

intake of vitamin D, vitamin B12, vitamin C, calcium, zinc, and a lower consumption of

dairies if compared with typically developed children .This means that food selectivity is not

just a matter of taste, but it is, most of all, a matter of health . Finally, children with ASD,

because of false myths, sometimes undergo to non-intentional and dangerous dietary

restrictions protocols (e.g., casein and/or gluten-free) based on non-evidence-based attempt to

improve behavioural disturbances or gastrointestinal symptoms.

Although a thorough empirical definition of food selectivity includes a high prevalence of

food refusal and limited food repertoire choices as part of the child’s regular diet ,the exact

aetiology of this aspect of ASD is not yet understood .Family eating behaviour and habits can

obviously affect atypical food intake . In fact, families who follow highly restricted diets

generally have children with more restrictive eating behaviour. However, atypical eating

behaviour in ASD needs a better understanding and specific explanations.

Food selectivity can be considered as an additional expression of the repetitive and restricted

behaviours of a child, which is part of the ASD phenomenology, resulting in a restriction to

variety of accepted foods.

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In Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM- V), oral

fixation for the same kind of food is considered as a manifestation of the insistence on same

food, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behaviour.

The study done by Suarez showed a positive correlation between restricted and repetitive

behaviours, measured through the Repetitive Behaviours Scale-Revised (RBS-R) and severity

of food selectivity.

Selection of food is often based on taste, texture, and presentation of food, and this issue may

be related to the sensory over responsivity, sensory low responsivity, a sensory-processing

disorder (SPD), expressed by an extreme over-reaction to sensations or extreme low reaction

to sensation from any of the seven sensory system components:

 Auditory- related to sense of hearing

 Visual – related to seeing
 Tactile – of or connected with the sense of touch
 Gustatory/oral - concerned with tasting or the sense of taste
 Olfactory- related to the sense of smell
 Vestibular- of, relating to, or affecting the perception of body position and
movement
 Proprioceptive- ability of a body to sense movement, action, and location

The hypothesis that sensory-over reaction may contribute to hypersensitivity to various food

textures or sensory low reaction may contribute to hyposensitivity to various food textures

and thus resulting in food selectivity that has been widely reported. According to a recent

review, there is clear evidence that impairment in sensory processing is positively associated

16
with feeding difficulties in children having autism. Changes in sensory perception also

appears to be positively associated with food neophobia, but current evidence is from two

small studies and thus warrants further investigation.

A block of scientific contributors have studied the link between the gut micro biota and

Autism Spectrum Disorder. Most studies have shown that children with Autism have an

altered gut micro biota, but, at the moment, it is impossible to properly compare these studies,

based on very disparate case histories and methods. For example, an increase in Bacteroidetes

and a corresponding decrease in Firmicutes were found in Autism subjects in two studies

when taken from their stool, but the relationship is reversed when dosed in the ileal mucosa.

Clostridia are increased in 2 studies and a significant reduction in Bifidobacterial was shown

in two studies while Sutter Ella, a germ never previously detected in the human intestine, was

found to be increased in both faeces and ileal mucosa in 2 independent studies.

Further studies recently approached the link between Autism and nutrition, exploring the role

of SGS (Sulforaphane-Glucosinolate) and the important benefits of vitamin D3

supplementation.

1. Dietary sulforaphane (they are antioxidants that cancel out free radicals i.e. tiny

particles that weakens and damage healthy cells ), well-known for its safety and lack

of toxicity, has been explored for its possible capacity to reverse abnormalities that

have been hypothesized to be associated with autism spectrum disorder, including

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 oxidative stress and lower antioxidant capacity, depressed glutathione synthesis,

reduced mitochondrial function and oxidative phosphorylation, increased lipid

peroxidation, and neuron-inflammation. Mr Singh and his colleagues conducted a

placebo-controlled, double-blind, randomized trial, involving adolescents and adults

with moderate to severe autism spectrum disorder, who received the phytochemical

sulforaphane—derived from broccoli sprout extracts—or indistinguishable placebo to

study the effects of behaviour of children when oral doses of sulforaphane given on

daily basis for 18 weeks, followed by 4 weeks. Without treatment, they were assessed

with the Aberrant Behaviour Checklist (ABC), the Social Responsiveness Scale

(SRS), and the Clinical Global Impression Improvement Scale (CGI-I Guy),

completed by parents/caregivers and physicians. Participants receiving placebo

experienced minimal change, whereas those receiving sulforaphane showed

substantial improvements, 34% according to Aberrant Behaviour Checklist, and 17%

according to Social Responsiveness Scale. Based on CGI-I, a significantly greater

number of participants receiving sulforaphane had showed improvement in social

interaction, abnormal behaviour, and verbal communication. Upon discontinuation of

sulforaphane, the total scores on all scales worsened to pre-treatment levels.

2. Regarding possible benefits of vitamin D3 supplementation, Mr Grossi and his

colleagues underlined that very narrow spectrum of habits in persons with autism

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 spectrum disorder may easily predispose to nutritional deficiencies of vegetables, both

cooked and raw (like tomatoes in particular), and fish (main source of vitamin D3).

Three randomized controlled trials (RCTs) included in a recent meta-analysis by Mr

Binging and his colleagues suggested that vitamin D supplements was very beneficial

for improving symptoms in children suffering with Autism, which was demonstrated

by the significantly lower Social Responsiveness Scale and Childhood Autism Rating

Scale (CARS) scores.

In conclusion, there is a lack of sufficiently robust evidence to support the specific dietary

interventions in children with Autism, although some small, documented real research-based

opportunities (e.g., vitamin D3; SGS) may open interesting glimmers. It is, therefore, so

much necessary to increase basic research on Autism spectrum disorder, which could provide

useful suggestions/ideas on better nutritional interventions. In all the families, whom having a

child/adolescent suffering with Autism, and even more in those presenting specific food

selectivity, a very close monitoring of correct eating habits by family paediatricians is

warranted, with the specific diagnostic procedures to prevent health issues, and possibly

adopting evidence-based approaches when needed (like psychoeducation and/or cognitive

behavioural therapy or ABA therapy).

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Autism Spectrum Disorder (ASD) refers to a broad range of condition characterised by facing

challenges with social skills, repetitive behaviour, verbal and non- verbal communication. All

these concerns are caused by differences in the various parts of brain that affects how the

child interact, communicate, learn and behave with others.

Although autism can be diagnosed at any age, it is described as a “developmental disorder”

because symptoms generally appear in the first two years of life. Till 2.8 years of age, the

child is considered under red flag with the showing concerns.

The abilities and needs of autistic children vary and can change with time. While some

children with Autism spectrum disorder can live independently, others have severe

disabilities and require life- long care and support. ASD often has an impact on academics

and employment opportunities.

Children with autism often have co-occurring conditions, including epilepsy, depression,

anxiety, intellectual disability and Attention deficit hyperactivity disorder (ADHD), Attention

deficit disorder (ADD) as well as challenging behaviour such as difficulty in sleeping and self

– harm.

The level of intellectual functioning among autistic children varies widely, extending from

mild impairment to severe levels.

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Diet and nutrition play an important and essential role in everyone's life. It helps to build a

healthy body and a strong mind. We know that food rich in nutrients can remove toxins from

the body, make an excellent immune system, curb hunger, and prevent obesity.

Children with autism and autism spectrum disorders (ASDs) are commonly affected by eating

disorders. Their preference for energy-dense food with low nutrition can alter their

metabolism, leading to the accumulation of oxidative radicals, causing them to deteriorate

mentally and physically.

Despite lot of efforts, parents of such children usually cannot control their children eating

because of tantrums and behavioural problems which are more common at that time. It is now

imperative for doctors and parents to work alongside nutritionists and dieticians to help these

children eat healthy to be fit and improve the quality of life.

Reports also indicate that individuals with autism and ASD are less likely to participate in

any physical activity, leading to overweight and obesity. These children are noted to be picky

eaters and prefer junk food: calorie-dense, carbohydrate-dense with high sodium, and less

nutrition. The decreased physical activities and increased erratic food habits can also lead to

long-term health imbalance.

According to researchers, "children with Autism spectrum disorder exhibited more food

refusal than typically developing children (41.7% vs. 18.9% of foods offered)." Another

research paper concludes that: "... children suffering with autism have significantly more

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feeding problems and may eat a significantly narrower range of foods than children who are

non- autistic."

This means that, if you have an autistic child whose eating is poor, you are not alone. Poor

eating habits may lead to a wide range of nutritional problems which, in turn, can lead to

problems ranging from health issues to attentional, developmental and behavioural problems.

Maybe your child would not eat broccoli, apples, nuts, or breakfast cereals. Or would not

touch yogurt, milk, applesauce, soup, or oatmeal. In both of these cases, there's follow a

pattern:

1. In the first case, the child is rejecting crunchy foods.

2. In the second case, they won't be able to tolerate smooth or gooey foods.

Autistic people can be more prone to sensory overload and sensory-defensive, meaning they

are easily upset by certain sensory experiences, and thus avoid certain foods. They may hate

bright lights or loud noise. They may also avoid strong smells and certain tactile experiences.

Certain foods have strong smells and tastes; others have specific textures that may be

appealing or disgusting to individual children.

Many individuals with autism have food aversions and sensitivities. Many also have

behavioural issues that make mealtime particularly challenging. For good reason, parents and

other caregivers of autistic children worry about providing them with scientific studies

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confirms these parental concerns and provides insights into the most common nutritional

deficiencies associated with autism.

Researchers at Marcus Autism Centre at Emory University School of Medicine reviewed and

analysed, peer-reviewed research relating to eating problems and autism spectrum disorder

(ASD). They found that children with Autism are five times more likely to have mealtime

challenges such as tantrums, extreme food selectivity and ritualistic eating behaviours.

They also found inadequate nutrition to be more common among children with autism than in

those unaffected by the disorder. In particular, they found an overall low intake of calcium

and protein. Calcium is crucial for building strong bones. Adequate protein is important for

growth, mental development and health.

Chronic eating problems also increase a child's risk for social difficulties and poor academic

achievement, the researchers note. This may also increase risk for diet-related diseases such

as obesity and cardiovascular disease in adolescence and adulthood.

The researchers expressed additional concern about alternative diets. Many parents reports

that their children’s showing autism symptoms and related medical issues improve when they

remove casein (milk protein) and gluten (wheat protein) from their diets. However,

casein/gluten-free diets (GFCF Diet) can increase the challenge of ensuring adequate

nutrition.

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Some research has shown that many children suffering from autism have low levels of

omega-3 fats.

Omega-3 fats like DHA are important for healthy growth and development. Research studies

have found that supplements containing omega-3 fats may help in reducing anxiety in

children and teens with autism, however it did not help to reduce other symptoms of autism

like communication and irritability.

Some of the common nutrition struggles that parents have reported include “selective eating”

related to food texture, taste, smell, and temperature, which can limit the certain foods that

children will eat. There may also be disruptive meal time behaviours present.

Additionally, parents have reported a primary reliance on “safe foods,” which tend to be

foods such as French fries, chicken nuggets, pizza, and other processed foods. The reason

why these foods tend to be considered “safe” to many children with autism is because they

will most likely be consistent anytime you prepare or eat these foods. For example, chicken

nuggets from a fast food restaurant will always taste the same, look the same, and smell the

same, which some children with autism prefer rather than taking a “risk” of eating a

blueberry, which could be sour, bland, sweet, mushy, or firm. Our fresh fruits and vegetables

tend to be more variable in flavour and texture, which can lead to a general distrust of these

foods, if the experience differs significantly from time to time.

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In conclusion, while there is ongoing research into the connection between autism and diet,

it's clear that a one-size-fits for all solution does not exist. An individualised, holistic autism

dietary management approach that considers the unique needs, sensitivities, and preferences

of each person with autism is essential. Collaborating with the healthcare professionals,

nutritionists, and therapists can provide valuable guidance in crafting a balanced and

nutritious diet that supports overall well-being.

As we continue with the complexities of autism, the role of diet and nutrition remains a

promising avenue for enhancing the lives of individuals on the spectrum. By combining

scientific knowledge with the empathy and a commitment to understanding individual

differences, we can work towards for a future where everyone, regardless of their

neurodevelopmental profile, has the opportunity to thrive properly.

Ultimately, the best approach to feeding your child would be to find a compromise between

giving what your child needs and adjusting it to what your child prefers. While diet will not

cure your child as a whole, you can always use diet to reduce diet-related problems and

improve your child’s overall health.

So can diet treat autism symptoms? The consensus of health experts state that there is no

significant evidence to prove that diet can cure autism symptoms completely. However,

several bodies of research have found that while diets do not treat autism symptoms, they can

alleviate some issues related to autism, such as gastrointestinal dysfunction and poor gut

health issues.
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In a study published earlier, gastrointestinal dysfunction was present in 49% of 164 children

with Autism. Additionally, 22% showed signs of diarrhoea, and 26 percent had constipation.

The findings confirm what many parents of children with ASD have long suspected: autism

and gastrointestinal issues are connected.

Gastrointestinal dysfunction or GID refers to diseases that occur in the gastrointestinal tract.

Some of these conditions include:

● Constipation – condition where there is difficulty and irregularity of bowel

movements. Symptoms include a bloated or distended stomach and pain when

experiencing a bowel movement

● Vomiting – is throwing up can be a symptom of a bacterial or viral infection, but

it can also be caused by food allergies, migraines, and other underlying medical

conditions.

● Diarrhoea – condition that involves watery stools and the urgent need to go to the

toilet. Beyond viral causes, diarrhoea is a symptom of celiac and Crohn’s disease

● Crohn’s disease – chronic bowel disease that inflames the gastrointestinal tract

anywhere between the mouth and the anus. The cause is unknown, but studies

have suggested a link to the immune system.

● Lactose intolerance – inability to digest lactose, a sugar found in animal milk

(cow, goat, and sheep), and can be brought about by Crohn’s or celiac disease.

26
 People who are having lactose intolerant experience bloating, stomach pain,

nausea, or diarrhoea within a few minutes of consuming lactose.

● Irritable Bowel Syndrome (IBS) – “abdominal discomfort associated with altered

bowel habits,” the symptoms are often sudden, persistent, and irregular bowel

movements that can either be constipation-predominant or diarrhoea-predominant.

● Gastro-oesophageal Reflux Disease (GERD) – known as heartburn or acid reflux,

this condition is caused by a weak oesophageal sphincter which makes partially

digested food go back up to the oesophagus.

● Celiac disease – autoimmune disorder triggered by the protein gluten. Many

parents of children with autism have found that excluding gluten from their

children diet improves symptoms as a response to the protein can damage the villi

(the small, finger-like projections in the small intestine), which interferes with

absorption and can lead to other health problems.

Body mass index (BMI) is a value derived from mass (weight) and height of a

person/individual. It is defined as the body mass divided by the square of the body height,

and is expressed in units of kg/m2, resulting from mass in kilograms (kg) and height

in metres (m).

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A common use of BMI is to assess how far an individual's body weight departs from what is

normal for a person's height. The weight excess or deficiency may, be accounted for by the

body fat (adipose tissue), although other factors such as muscularity also affect BMI

significantly.

The WHO (world health organisation) regards an individual BMI of less than 18.5 as

underweight and possibly indicative of malnutrition, an eating disorder, or other health

problems, while a BMI of 25 or more is considered as overweight and 30 or more is

considered obese. These ranges of BMI values are valid only as statistical categories.

BMI is used differently for individual aged 2 to 20. It is calculated in the same way as for

adults but then compared to typical values for other children or youth of the same age.

Instead of comparison against fixed thresholds for underweight and overweight individual,

the BMI is compared against the percentiles for children of the same sex and age.

A BMI that is less than the 5th percentile is considered underweight and above the 95th

percentile is considered obese. Children with a BMI between the 85th and 95th percentile are

considered to be overweight.

Studies in Britain from 2013 have indicated that females between the ages of 12 to16 had a

higher BMI than males of the same age by 1.0 kg/m2 on average.

BMI numbers for different ages and genders have different interpretations. A comparison

with other children is mandatory as children develop muscles with age, and boys tend to have

28
more muscle than girls. A healthy BMI for children in the percentile lies between the 5th

percentile and the 85th percentile.

29
30
31
There are several health problems in a child if the BMI is not check. Some of the health

issues children could be face in case of overweight and underweight are :

Risks associated with obesity=

 High blood pressure

 High Cholesterol

 Type 2 diabetes

 Sleep apnea and asthma

 Liver diseases

 Problems in joints and muscles

 Stress

 depression and other behavioural problems owing to low self-esteem

Risks associated with being underweight=

 Respiratory disorders

 Weak Immune system

 Prone to injuries

 Nutritional deficiencies

People with autism often may repeat behaviors/ have narrow, restricted interests. These types

of behaviour can affect eating habits and food choices, which can lead to the following health

concerns.

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 Limited food selection or strong food dislikes

Someone with autism may be sensitive to the taste, smell, color and texture of foods.

They may limit/ totally avoid some foods and even whole food groups. Dislikes may

include strongly flavoured foods, fruits and vegetables or certain textures such as

slippery or soft foods.

 Not eating enough food

Children with autism may have difficulty focusing on one task for an extended/long

period of time. It may be hard for a child to sit down at one place and eat a meal from

start to finish.

 Constipation

Problem may be caused by a child's limitation of food choices, low physical activity

levels or medications. It typically can be remedied by gradually increasing sources of

dietary fibre, such as bran cereals, fruits and vegetables, along with plenty of fluids

and regular physical activity.

 Medication interactions

Stimulant medications used with autism can lower the appetite. This can reduce the

amount of food a child may eats, which may affect his/her growth. Other medications

33
may increase appetite or affect the absorption of certain vitamins and minerals. If your

child takes medication, ask your healthcare provider about possible side effects.

BASIC CATEGORISATION OF BMI

Category BMI (kg/m2) BMI Prime

Underweight (Severe thinness) < 16.0 < 0.64

Underweight (Moderate thinness) 16.0 – 16.9 0.64 – 0.67

Underweight (Mild thinness) 17.0 – 18.4 0.68 – 0.73

Normal range 18.5 – 24.9 0.74 – 0.99

Overweight (Pre-obese) 25.0 – 29.9 1.00 – 1.19

Obese (Class I) 30.0 – 34.9 1.20 – 1.39

Obese (Class II) 35.0 – 39.9 1.40 – 1.59

Obese (Class III) ≥ 40.0 ≥ 1.60

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Poor eating habits and feeding issues have several different causes and many levels of

severity. Resolving problems with feeding, picky eating, food intolerances, and nutritional

deficits can have a positive impact on child's life.

35
 AIMS AND OBJECTIVE

1. To show that providing various supplements of different micro or macro nutrients

may help the child to lead a healthy lifestyle as an autistic kid.

2. To help the parents and guardians of autistic kids understand the value of a healthy

balanced diet and the importance of nourishment in kid’s life.

3. To determine the problematic areas of behaviour of autistic children to make sure,

they should get balanced diet in order to fulfil their daily nourishment value.

4. To figure out what can be used as an alternative for their diet especially for autistic

kids who are picky eaters or selective eaters.

5. To help parents or caregivers understand the nutritional elements of various food

items and their importance to consume for kids with autism.

6. To help therapist, parents and caregivers understand the body functioning of kids and

the figure out the best options in food items that can be used for autistic kids without

getting them cranky or irritated.

36
 REVIEW OF LITERATURE

1. Diet and nutrition plays a very essential role in every individual life. It helps to build a

healthy body and a strong mind. Food which are rich in nutrients can remove various

toxins from our body, make our immune system more stronger, to limit or control our

hunger, and prevent obesity. Obesity is one of the most concerning and fastest

growing problems these days. It affects not only adults but also adolescents and

children. Children with autism spectrum disorders (ASDs) are commonly affected by

eating disorders. Children with autism give preference to energy-dense food with low

nutrition which alter their metabolism, leading to the accumulation of oxidative

radicals, which may deteriorate them mentally and physically. Although, dieting and

losing weight are now commonly seen in the general population, it is becoming

difficult to bring awareness to the parents of children with special needs about diet,

nutrition, and obesity. Despite efforts, parents of such children unable to understand

the eating pattern of their children because tantrums and behavioural problems are

more common. It is now very imperative for doctors and parents to work alongside

with the nutritionists and dieticians to help these children to eat healthy so that they

can improve the quality of life.

2. Autism spectrum disorder is one of the rapidly growing neuropsychiatric disorders.

Changes in the balance of intestinal microorganisms can cause a variety of symptoms

37
 indicating a strong relationship between the gut and the body. Active dietary plan

including the use of dietary supplements and elimination of certain products such as

gluten, casein and processed foods might help to reduce the severe outcomes. After

knowing about all the ingredients present in the food, we can avoid and reduce the

symptoms associated with Autism Spectrum Disorder. However, further research is

required to confirm these findings.

3. Children with autism are differentiated from normal children after looking their

symptoms like lack of social interaction and stereotypical behaviour. Autism is a

heterogeneous condition with unknown aetiology. Research has grown significantly

and has suggested that environmental risk factors acting during the prenatal period

that could influence the neurodevelopment of offspring. The literature suggests that

the diet followed by mother during pregnancy play a fundamental role in the cause

and development of disease or abnormal condition like autism. A maternal diet that is

high in nutrients has been associated with an increase or reduction in the risk of

develop Autism Spectrum Disorders (ASD). The diet of children is also an important

factor for the worsening of symptoms. Children with autism have food selectivity and

limited diets due to smell, taste, or other characteristics of foods. This conclude that

eating routines and food intake patterns, will result in consequent deficiency or excess

of some elements. Several studies have tried to show a possible relationship between

38
 nutritional status and autism. In this we describe, emphasizing the limits and benefits

of maternal diet during gestation period.

4. Each individual diet and nutrition play an important or vital and significant aspects in

their lives. It supports the development of a healthy mind and strong body. We are

aware that eating a diet which are high in nutrients can help the body to remove out

impurities and strengthen the immune system, Because of the disorder early onset, it

requires immediate treatment to control the burden it places on the body, mind,

finances, and society. Nutrition playing a great role in every individual daily life. The

food or liquids affects our body and health because each food/ liquid contain

particular nutrition which is very necessary for our physical and mental growth. A

particular level of any particular nutrition is essential for our body. So we are

researching on what food we have to take, how much and what type of nutrition

contain a particular food.

5. The results showed that feeding problems are present in children with autism. This is

essentially reflected in their refusal of some vegetables, fruits and meats, pica,

selectivity to starches and limitation to food varieties. A selective diet can lead to

nutritional deficiencies, if varieties of foods remain restricted, which makes feeding

problems a potential health risk. However, studies assessing nutrient intake in

children with autism have shown conflicting results. Because feeding children and

family mealtimes are an integral part of child-rearing and family life, the presence of

39
 feeding problems concurrent with autism represents an increased burden for families

of children with autism. In fact, due to the clinical characteristics of their disease,

children with autism often attribute this failure to their parents’ skills about food,

justifying the need for a systematic dual approach, such as careful evaluation and an

appropriate treatment to an autistic child. Further research is thus necessary to better

target this problem. In this context, clinical implications require comprehensive and

early treatment of feeding problems in children with autism to prevent the

perpetuation of some difficulties in the mother-child relationship in connection with

early failures of feeding and give later targeted therapy. It is therefore important to

raise the awareness of the clinicians working with children with autism to

systematically look for feeding problems in a global perspective in order to act on

time and prevent nutritional deficiencies and mother-child interaction disorder.

6. There is a history of a child with autism who, after limited response to other

interventions following her regression into autism, was placed on a gluten-free,

casein-free diet (GFCF DIET), after which she showed marked improvement in

autistic child and medical symptoms. This gluten-free casein-free ketogenic diet used

medium-chain triglycerides rather than butter and cream as its primary source of fat.

Medium-chain triglycerides are known to be highly ketogenic, and this allowed the

use of a lower ratio level (1.5:1) leaving more calories available for consumption of

vegetables with their associated health benefits.

40
Secondary benefits included resolution of morbid obesity and improvement of cognitive

and behavioural features. Over the course of several years following her initial diagnosis,

the child’s Childhood Autism Rating Scale score decreased from 49 to 17, representing a

change from severe autism to non-autistic, and her intelligence quotient (IQ) increased 70

points that is a subsequent and drastic difference.

7. Low vitamin D status in prenatal, postnatal and in early childhood has been

hypothesised as a risk factor for neurodevelopmental disorders, specifically Autism.

Animal and human cellular, biological, and physiologic studies have provided

compelling evidence for numerous roles of vitamin D supplements in various body

processes, some of which are involved in the pathobiology of Autism.

Our literature review identified a large number of observational studies but very few

intervention trials investigating the relationship between vitamin D and ASD.

Conclusions are not yet possible due to the inconsistency in results, different

methodological approaches are employed, and very few trials in the current literature.

However, there are some indications that early exposure to inadequate vitamin D may

interact with other factors and contribute to the aetiology of autism, low vitamin D status

might be highly prevalent in populations with Autism, and intervention with vitamin D

might be beneficial in reducing autism symptoms among those who have autism. Until

better research is done health care providers/therapists and researchers are advised to

41
consider vitamin D-related factors as potential preventive and disease-modifying

measures for Autism.

8. Autism spectrum disorders (ASDs) is an early-onset neurodevelopmental disorders.

The key symptoms of ASD include social deficits, verbal and non-verbal

communication deficits, and restricted- repetitive patterns of behaviour, interests, or

activities. Dietary patterns have been evidenced to be related to maternal nutritional

status that might lead to different metabolic conditions, and maternal metabolic

dysfunction has been observed to be associated with Autism. Furthermore growing

evidence suggests that the gut microbiota play a role in the pathophysiology of

Autism. Differences in composition of the gastrointestinal (GI) microbiota in children

with Autism compared to unaffected siblings and/or healthy unrelated controls have

been reported in various studies. The above-mentioned Autism factors and symptoms

can be regulated by proper nutrition. The importance of nutrition and its possible

impact on autistic patients is key to integral therapy. According to numerous research

studies, various nutritional approaches succeeded in reducing the severity of patients'

core Autism symptoms. The numerous options for diet that is used in the Autism

therapy, as described in the scientific literature, are related to the problem of choosing

an appropriate nutritional treatment. Each nutrition programme needs to be

personalised and tailored to an individual patient.

42
9. Mazurek et al. investigated the relationship between sensory over-responsivity and

Gastro-intestinal problems. They found that those with chronic Gastro-intestinal

problems had higher levels of sensory over-responsivity. Increasing numbers of

Gastro-intestinal problems were associated with higher levels of sensory over-

responsivity. Sensory over-responsivity also predicted chronic Gastro-intestinal

problems.

Mulloy et al.conducted a systematic review on gluten-free and casein-free diets

(GFCF diet) in the treatment of autism spectrum disorder. The authors concluded that

the published studies they located do not support the use of GFCF diets in the

treatment of ASD. The authors commented on negative consequences for the use of

the GFCF diet, such as use of the treatment resources, stigmatization, and reduced

cortical bone thickness. The authors recommended that should a child with Autism

experience behavioural changes seemingly associated with change in diet,

practitioners should consider testing the child for various allergies and food

intolerances and eliminate identified allergens or irritants from their environment.

10. Researchers found that children with ASD are five times more likely to have

mealtime challenges such as tantrums, extreme food selectivity and ritualistic eating

behaviours. They also found inadequate nutrition to be more common among children

with autism than in those unaffected by this disorder. In particular, they found, an

overall low intake of calcium and protein. Calcium is very crucial for building strong

43
 bones. Adequate protein is important for growth, mental development and health.

Chronic eating problems also increase a child's risk for social difficulties and poor

academic achievement. This may also increase risk for diet-related diseases such as

obesity and cardiovascular disease in adolescence and adulthood. Many parents report

that their children’s autism symptoms and related medical issues improve when they

remove casein (milk protein) and gluten (wheat protein) from their diets. However,

casein/gluten-free diets (GFCF diet) can increase the challenge of ensuring adequate

nutrition.

11. “Selective” or “picky eating” is a frequent problem in children with autism spectrum

disorders (ASD) now a days. Many of these children do not treat sensory input,

particularly olfactory, auditory, visual, and tactile information in the same manner as

their typically developing peers of the same age. The purpose of this paper was to

examine the relationship between problems of sensory processing and the number of

eating problems in children with Autism. Of 95 children with Autism, 3 to 10 years of

age, 65 percent showed a definite difference and 21 percent a probable difference in

sensory processing on the total score of the Short Sensory Profile. These results were

significantly related to an increase in the number of eating problems measured by

the Eating Profile. These results could not be explained by age, sex, mental

retardation, attention deficit disorder (ADD), attention deficit hyperactivity disorder

44
 (ADHD) or hyperactivity-impulsivity disorder. Timely interventions focusing on the

sensory components of eating must now be developed.

12. Different dietary approaches should have been attempted for the treatment of autism,

but only three of them have been subjected to clinical trials:

 education in healthy nutritional habits

 supplementation diet

 elimination diets

On the other hand, for multiple reasons, the number of people who adopt vegetarian

and gluten-free diets (GFD) increases daily. More recently, a new entity, non-celiac

gluten sensitivity (NCGS), with a still evolving definition and clinical spectrum, has

been described. Although, the benefits of GFD are clearly supported in this condition

as well as in celiac disease, in the last two decades, GFD has expanded to a wider

population. In this review, we will attempt to clarify, according to the existing

evidence, which are myths and facts of these diets.

13. A wide range of disorders with aberrant brain function include autism. The kind of

severity of this illness vary widely. The first two years of a child's life are when

symptoms are typically noticed. Communication problems, as well as social and

behavioural activities, are caused by the disease group. To enhance their quality of

life and stop their existing condition from getting worsen, people with autism

spectrum disorder (ASD) should be attentive to what they eat. Nutrition can

45
 frequently provide relief for Autistic patients who have digestive problems. The

usefulness of various diets for people with Autism must be further studied.

14. Autism spectrum disorder (ASD) comprises a group of heterogeneous constellations

characterized by deficits in cognition, communication, and social skills. Autism has

no established aetiology and its search for reliable biomarkers has proved to be

difficult, giving rise to alternative theoretical accounts, including those related to

nutrition. One such account posts that the proteins, gluten and casein, derived from

wheat and milk respectively, are causally involved in the symptomatic expression of

this disorder. As a consequence, a diet devoid of such proteins has been hypothesized

to ameliorate the behavioural symptoms of children with Autism. The scope of the

present review is to analyse the effects of gluten-free and casein-free (GFCF) diets on

children with autism.

15. To assess the extent of the scientific literature on avoidant/restrictive food intake

disorder (ARFID) in children with autism in order to evaluate and synthesize the

evidence on :

(a) the nature of feeding and eating difficulties in children with autism

(b) the consequences of a severely restricted diet

(c) what is known about effective treatment approaches.

46
 Diet plays a major role in determining the nutritional value that can be provided to a

person/ child. The type of food offered and the type of food preferred should be

correlated in order to fulfil the everyday nutritional demand of the child’s body in

order to carry out all the activities of daily living.

16. Nutrition-related challenges are common among children with autism spectrum

disorder (ASD). They include food selectivity, sensory sensitivities, gastrointestinal

complications, oral motor delays, and nutrient deficiencies. As the prevalence of

nutrition-related challenges increase in children with Autism, it is important for a

multi-disciplinary team of medical professionals to be well versed in addressing

paediatric nutrition for this population. The purpose of this study was to investigate

medical professionals’ perceptions of barriers, facilitators, and the necessary

qualifications to provide effective nutrition care for children on the autism spectrum.

Thematic analysis of semi-structured interviews with 21 medical professionals

identified 3 keys themes:

(1) barriers for providing effective nutrition care for children with ASD

(2) facilitators for providing effective nutrition care for children with ASD

(3) rationale for who is the most qualified medical professional to provide nutrition
care for children with ASD.

17. Diet therapy of autism is one of the safest methods to prevent the progression of

disease and improve the functional state of the central nervous system and other

47
 organs. It should be recommended that industrial products containing unwanted

xenobiotics, aluminum, soy, estrogens, pesticides, sweeteners, trans fatty acids be

excluded from use. The nutrition of a patient with ASD should provide the body with

the necessary energy, plastic and regulatory factors, take into account age and

nutritional status. To research further on diet therapy to improve various symptom of

autism.

18. Food selectivity is a problem in many of the lives of children with autism. Limited

food repertoires can negatively affect nutritional status and the quality of life for those

children and their families suffered with autism spectrum. The precise cause of this

food selectivity is unknown although a number of reasons have been posted. This

inability to pinpoint an exact cause has lead to a debate between researchers about

whether behavioural or physiological issues have to be blame. This paper first

explores both of these options. Then, a new clinical program at WMU OT Unified

Clinics is described that focuses on a holistic approach used by occupational

therapists to treat food selectivity.

19. The downside of food preference is that it can cause some negative consequences on a

person’s health. For instance, a diet very high in carbohydrates and low in protein,

fruits, and vegetables can lead to higher blood glucose level and triglyceride levels.

This has the possibility of leading to malnutrition or above average weight. It might

also lead to endocrine disturbances such as diabetes. This type of diet can also lead to

48
 higher rates of dental cavities, especially when in combination with poor dental

hygiene. Children with autism often have a low consumption of vitamin D, vitamin

B12, vitamin C, calcium, zinc, and dairy supplements as compared to the general

population.

20. The potential impact of diet on autism has gained attention due to the recognition that

nutrition plays a vital role in overall health and well-being. While research on the

specific effects of diet on autism is ongoing, some studies have suggested that certain

dietary interventions may help manage symptoms and improve quality of life for

individuals with autism. It is important to note that there is significant variability in

how children with autism respond to dietary changes facing in their life. What works

for one children may not work for another. Additionally, dietary interventions should

always be approached with caution and under the guidance of healthcare professionals

like dietician, psychologist, occupational therapist. It is essential to consider

individual needs, preferences, and any underlying health conditions when

implementing dietary changes in their life.

49
 MATERIAL AND METHODS

⮚ SOURCE OF DATA: Pandit Deendayal Upadhyaya National Institute for Persons

with Physical Disabilities, Delhi

⮚ STUDY DESIGN : experimental study

⮚ SAMPLING METHOD : non- probability convenient sampling technique

⮚ SAMPLE SIZE : 10

⮚ INCLUSION CRITERIA :

o Children with Autism Spectrum Disorder

o Children with age group 3-6 years

o Children with moderate to severe autism on sensory toddlers scale

⮚ EXCLUSION CRITERIA :

o Children other than ASD with genetic disorders and other behaviour disorders

o Children other than age group of 3-6 years

50
 ⮚ MATERIAL USED

The purpose of this study was aimed to determine the nutritional assessment of children
suffering from autism.

The rules and regulation of ethical committee of university were followed while
conducting the result.

After taking permission from the parents, data were be collected with the help of pre-
tested data collection questionnaire.

 SCREENING TOOL :
 Standardized checklist – sensory profile (age 3 to 6) - This scale is
used to identify the oral sensitivity in children with
autism spectrum disorder.

Scoring for oral sensitivity ranges from:

RANGE REMARK

0-1 much less than others

2-5 less than others

6-15 just like majority of others

16-19 More than others

20-35 much more than others

 Non standardised checklist and questionnaires

Questionnaire Remark (yes/no)

51
 Eats fruit
 Has problems with chewing food
 Enjoys eating
 Chokes or gags at mealtime
 Will try new foods
 Eats meat or fish
 Takes longer than 20 minutes to finish a meal
 Drinks milk
 Comes readily to mealtime
 Eats junky snack foods but will not eat at a
mealtime
 Vomits just before , at, or just after mealtime
 Eats only ground, strained or soft food
 Gets up from table during meal
 hold food in his/her mouth and doesn’t swallow it

 whines or cries at feeding time

 eats vegetables
 show tantrums at mealtime
 eats starches like potato, noodles
 has a poor appetite
 spits out food
 delays eating by talking
 would rather drink than eat
 refuses to eat but requests for food immediately
after the meal
 tries to negotiate what he/she will eat and what not

 has required nasal- gastric feeds to maintain proper

nutritional status

 PROCEDURE AND DATA COLLECTION

Subjects will be selected on the basis of inclusion criteria. After explaining the study

and obtaining the consent from parents baseline assessment will be done using

sensory profile 2, questionnaire on food behaviour.

52
 RESULTS

ORAL SENSITIVITY DATA ANALYSIS

S.NO. NAME OF PATIENT AGE/SEX DIAGNOSIS RANGE

1 REYANSH GUPTA 4Y/M AUTISM 16-19

2 AARAV SINGH 3Y/M AUTISM 2-5

3 SANIDHYA 5Y/M AUTISM 6-15

4 HARSHIT RANA 3Y/M AUTISM 16-19

5 SAGRIKA 4Y/F AUTISM 6-15

53
 6 ANANYA 3Y/F AUTISM 20-35

7 DEVANSH 5Y/M AUTISM 6-15

KHANDURI

8 SHIVANSH 3Y/M AUTISM 16-19

9 SHREYAN NEGI 4Y/M AUTISM 16-19

10 MD ARSH 3Y/M AUTISM 18-30

80%

70%

60%

50%

40%

30%

20%

10%

0%
yes no

ORAL SENSITIVITY ISSUES IN CHILDREN WITH AUTISM

Result showed that:

70% children facing problem in oral sensitivity
30% children not facing problem in oral sensitivity

54
 45%

40%

35%

30%

25%

20%

15%

10%

5%

0%
underweight normal weight overweight obese grade 1 obese

CLASSIFICATION OF BMI

Result showed that:

40% children were diagnosed with underweight.
30% children were diagnosed with normal weight
10% children were diagnosed with overweight.
10% were diagnosed with obese.
10% children were diagnosed with grade 1 obesity.

55
 80.00%

70.00%

60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00%
yes no

FREQUENCY OF STEREOTYPICAL BEHAVIOUR IN CHILDREN WITH AUTISM

Result showed that:

70% children had stereotypical behaviour.
30% children didn’t had stereotypical behaviour.

60%

50%

40%

30%

20%

10%

0%
daily 3-4 times aweek once aweek never

FREQUENCY OF SUGAR & SAVOURY CONSUMPTION IN AUTISTIC CHILDREN

56
Out of 10 children:
20% were not consuming sugar and savoury at all,
30% children consumed sugar and savoury 3-4 times per week and
10% children consumed sugar and savoury once a week.
50% children consumed sugar and savoury daily.

DISCUSSION

The study was conducted to assess the effect of different dietary patterns of autistic children.

In the experimental study done by the researcher showed that the children with the autism

displayed less desire for the social interaction/communication as compared to the normal

developing children. Assessment indicated that 74.3% children showed low response to

command, 70% children showed restricted behaviours to command, 70.5% children have

speaking problems, 79.7% children have aggressive behaviour and 62.4% children facing

57
health issue .In this study, it was also suggested that these behaviours can be modified by

psychotherapies, by the clinical services and trained their parents and caregivers. In current

evaluation, 28.7% autistic children have different sedentary life style. Study showed that

autistic children spent more than one hour in sedentary condition on weekdays and schedule

data about their routine was conducted by their parents and caregiver. Autistic children

mostly enjoy screen time, this study also suggested that they spent more than 2.5 hours on

screen daily while typical brain developing children spent 1.6 hours daily on screen.

Assessment showed that 70% children showed restricted behaviours to diet. Research done

by RUBY GUPTA highlighted that children with Autism were showing nutritionally

vulnerable behaviours because they were selective or had picky eating patterns which lead

them towards restricted diet intakes. Finding showed that 10% children are overweight.

According to the result 40% had BMI in range of underweight and 20% had BMI in the range

of obesity. A research conducted in Spain demonstrated that a gluten- as well as casein-free

diet lead to weight loss plus lower BMI. A cross-sectional study was done among the 10

autistic children within the age group of 3-6years. Results suggested that most common type

of malnutrition was underweight, wasting and stunting. Underweight and wasting were

significantly higher in boys as compared to girls and wasting was higher in girls. According

to present assessments 22.4%, 29.1%, 37.6%, 37.6%, 28.3%, 20.3% and 37.1% children are

consuming spinach, salad, potatoes, cucumber, carrots and radish respectively. Similarly

27.0%, 37.1%, 24. 9% and 25.3% autistic children are consuming mango, guava, apple and

58
peach respectively. And results showed that autistic child were consuming significantly more

sweetened beverages and snack foods as compared to normal children. Autistic children

consuming vegetables and fruits significantly less than the typically developing children.

The researcher showed that if the children with autism spectrum disorder have citrus diet

including citrus fruits like strawberries, oranges, cherries and vitamin B12 rich diet and

omega rich supplements in their daily routine diet.

The diet should include probiotics and other vitamin and mineral rich supplements that

should be consumed on a daily basis with a proper routine plan.

A number of parents or professionals working with children having one of the autism

spectrum disorders have noted an association between the child's diet and severity or

frequency of symptomatology; with different mechanism proffered in the explanation of this

association. There have also been suggestions that food additives or food substances may

play a very important roles in the aetiology of Autism; and recently, animal studies have

demonstrated that propionic acid (PA), a dietary short chain fatty acid and common food

additive induces neuro-inflammatory responses and a number of behavioural changes in rats

that are similar to that observed in Autism spectrum disorder. The alteration in behaviour, as

well as neuro-pathological and biochemical effects of intra-ventricular administration of

propionic acid also increased support for the hypothesis that autism may be a systemic

metabolic encephalopathy.

59
Earlier studies had demonstrated that impairments in synapse formation/synaptic plasticity,

culminating in functional and cognitive impairments are core causative factors that

underlying ASD pathology. Genetic studies have also proven that several identified risk

genes for ASD are involved in the regulation of synaptic plasticity; and changes in the protein

products of these genes can alter brain neuronal connectivity by affecting the strength

/number of synapses in the brain. Brain alterations such as aberrant cortical plasticity and

meta plasticity had been implicated in the pathophysiology of ASD, and are also

demonstrable in both animal models of ASD and in humans with ASD.

The role of nutrition in modulating neural plasticity has been reported; and two nutrient (iron

and choline) deficiencies and their effects on brain synaptic plasticity have been studied

extensively. The Hypotheses suggesting that foetal/neonatal nutritional deficiencies could

compromise the integrity of the dendritic arbours or result in epigenetic chromatin

modifications that may decrease the expression of (or permanently cause a deregulation of

synaptic plasticity) genes that regulate protein polymerisation have been suggested as

possible mechanisms. Studies have shown that nutritional components such as N-3

polyunsaturated fatty acids play important roles in the pathogenesis of ASD through their

ability to regulate synaptic plasticity; hence, its deficiency during critical periods of brain

development is strongly linked to the development of Autism spectrum disorder.

Nutrition has been considered an important factor in the maintenance of not only brain

function but also brain biochemistry. Studies have demonstrated that alterations in vitamin

60
and mineral nutrient intakes may impact brain biochemistry, through their roles as

coenzymes. Also, the synthesis of a number of neurotransmitters of brain (including serotonin

and dopamine) are regulated by dietary fluctuations in the availability of their nutrient

precursors. In Autism spectrum disorder, there have been reports linking alterations in brain

levels of dopamine, serotonin, acetylcholine and γ-amino butyric acid with derangement in

vitamins, minerals and trace elements; although, the exact relationship among these factors

and their interaction with genes and proteins that are important in brain development and

growth are still been studied. Increasingly there are some suggestions that daily nutrient

supplements including essential vitamins, minerals, specific amino acids and omega-3 fatty

acids may be effective in ASD management, due to their ability to modulate neurotransmitter

levels.

Intake of macronutrients and micronutrients in children with Autism has been a matter of

scientific investigations; with authors reporting lower, higher, or normal levels of intake

(compared to the recommended amounts) which may be a reflection of the highly-

heterogeneous nature of the disorders. However, evidences still is in favour of deficiencies of

several micronutrients, and macronutrient imbalance may contribute to the higher rates of

obesity in these children.

Over the years, it had been shown that children with Autism spectrum disorder tend to

harbour nutritional deficiencies that may be less seen in the normal population. Studies

conducted in children with Autism (examining different body tissues such as blood and hair)

61
had reported lower levels of selenium, zinc, magnesium, vitamins A and vitamin E, vitamin B

complex, vitamin D.

Other deficiencies that had been reported include those of potassium and choline. More

studies are showing that children with Autism tend to consume significantly fewer

macronutrients compared with children without Autism; a reflection of a general challenge

regarding their nutrition. In a study that was conducted between 10 children with Autism,

having selective-eating and nutritional deficiencies were found to be more common and the

children with Autism were found to consume significantly fewer foods on an average,

compared to normally-developing children. They were also found to have taken lower

amounts of protein, calcium, vitamin B12 and vitamin D. Hence, in children with Autism,

selective-eating and a significantly-higher risk for the development of nutrient deficiencies

tend to go hand-in-hand.

Food-selectivity in children with Autism has been found to typically involve strong

preferences for starchy, processed and snack foods, along with a bias against fruits and

vegetables; also, this food-selectivity is usually a chronic condition that persists into

adolescence and adulthood. Food-selectivity is a behaviour that is likely to worsen

micronutrient deficiencies and increase the risk of associated metabolic disorders, over time.

Tackling with micronutrient deficiency in Autism is a difficult task, and as shown by a cross-

sectional study; deficits in vitamin D, calcium, potassium, pantothenic and choline may

persist in a significant percentage of patients, despite intake of nutritional supplements.

62
Micronutrient deficiency may also correlate with the severity of behavioural symptoms in

children with ASD. In a study conducted in Chongqing, China, in which serum ferritin,

folate, vitamin B12, 25(OH) vitamin D, and vitamin A concentrations in children with ASD

were determined and correlated with behavioural assessment of severity of ASD using the

Childhood Autism Rating Scale (CARS); after adjusting for sex, vitamin A concentration (in

particular) was found to be negatively correlated with the CARS score. Therefore, the finding

supports the notion that a low serum vitamin A level may be a risk factor for exhibiting the

symptoms of ASD; however, a direct explanation of the underlying mechanism is not yet

available.

Presently, with regards to nutritional deficiencies and Autism spectrum disorder, the

following are obvious:

a) maternal malnutrition (in relation to certain nutrients) is a risk factor for development of

Autism in the offspring

b) Deficiencies of certain nutrients are associated with expression or increasing severity of

Autism symptoms;

c) Different eating habits that are found in Autistic patients may likely lead to or worsen

bodily deficiency of certain nutrients.

Therefore, while it is still difficult to establish that certain early-life nutritional deficiencies

will definitely cause Autism; available evidences are in favour of strong associations between

63
nutritional deficiencies and ASD, and these associations are in the area of causation, severity

of symptoms, and as co-morbidity.

Maternal nutritional deficiency is believed to play a very important role in the development

of Autism spectrum disorder in offspring. Nutrients, whose deficiencies have been linked to

increased risk of ASD include folic acid and vitamin D. More recently, low iron intake in

pregnancy was associated with a 5-fold greater risk of autism in the offspring of mothers

aged 35 or more, or those with conditions such as obesity, hypertension or diabetes.

Effect of maternal vitamin D deficiency on the occurrence of ASD has gained considerable

attention. Experimental induction of vitamin D deficiency in pregnant rat dams has been

reported to affect foetal neurodevelopment, and behaviour in adult offspring. Also, in

humans, prenatal vitamin D deficiency is known to be associated with a range of brain-

related disorders in offspring, including impairment of language development and cognitive

functioning. Children born to dark-complexioned women who reside in high-latitude

countries (such as Sweden) are at a particularly high risk of ASD with intellectual disability,

and this has been linked to very low maternal vitamin D levels due to melanin absorption of

ultraviolet B radiation .

Solid, replicated research studies have shown that:

 Autistic children have more eating issues than other typical growing children.

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  Autistic children have more Gastro-intestinal problems than other children. The

reason for this has not yet been determined, though there are several theories.

 Some children with Autism are sensitive to some specific foods such as casein,

gluten, artificial sweeteners, and dyes (this is true of non-autistic children as well).

 Some autistic kids, probably because of picky/selective eating habits, have nutritional

deficits that can be alleviated through supplements.

 Some problematic behaviours are almost certainly increased by food/nutrition-related

issues and can be alleviated through a variety of means, including dietary changes and

supplements.

 There is an increased risk of eating disorders, such as anorexia and bulimia, among

people on the autism spectrum.

According to current knowledge after the research, autism has not been shown to be caused

by particular foods, and it can't be cured through nutritional changes of any kind but it can

slow down some symptoms.

CONCLUSION

 FUTURE SCOPE & LIMITATION:

Nutritional therapy – additive approach and subtractive approach along with quality

occupational therapy.

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The children with autism spectrum disorder should be provided with nutritional therapy along

with quality occupational therapy.

There should be two approaches that need to be used by the consultant occupational therapist

and they are:

(a.) Additive approach

(b.) Subtractive approach

ADDITIVE APPROACH -

Children with Autism often reject bitter or sour tastes. This preference can cause obesity,

diabetes, and dental caries. Additionally, they usually have inadequate vitamin D, vitamin

B12, vitamin C, calcium, zinc, and other micronutrients. Supplements generally in use

include vitamin B6, vitamin C, vitamin D, vitamin B12, dietary fatty acids (omega-3 fatty

acid and cod liver oil), melatonin, folic acid, probiotics, L-carnitine, iron, magnesium, zinc

and copper. In addition, it is imperative to include fresh fruits and vegetables and avoid sweet

foods in the diet of a child with Autism. Instead, focus on a natural and varied diet, avoiding

pesticides, preservatives, artificial ingredients, and fast or processed foods.

● Citrus diet: To increase vitamin C levels, children with autism can consume fruits

and vegetables such as spinach, cauliflower, bell peppers, citrus, strawberries,

bananas, potatoes, tomatoes, cherries, and more.

Eating citrus fruits like oranges or grapefruit is a better option than squeezing and drinking

juice from the fruit alone. This is because there are significantly higher amounts of vitamin C

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in the fruit itself than in the liquid. Eating fruit rich in vitamin C is also more helpful because

vitamin C oxidizes upon exposure to oxygen (meaning while baking, cooking, freezing, or

thawing).

Although dietary supplements can contain ascorbic acid, they should only be used if there is a

deficiency present. Once this is confirmed, supplements may be consumed daily.

● Vitamin B12 diet: Vitamins and minerals are required for normal growth and

development of children. Vitamin B-12 is known to be necessary for the synthesis of

myelin in the body. The development and pattern of myelination follows a well-

described neuroanatomical arc, progressing in a posterior-to-anterior and centre-

outwards spatiotemporal pattern that corresponding to maturing cognitive

functions .That is, there is a strong overlap in the emergence of a specific cognitive

function and the myelination of brain regions and networks sub serving that function.

Hence it was hypothesized by several researchers that childhood neurodevelopmental

anomalies like ASD or ADHD could be related to a deficiency of Vitamin B-12.

● Digestive enzymes and probiotics: Digestive enzymes aid food absorption by

breaking down large molecules of food into smaller molecules, allowing for easier

absorption, digestion, and elimination of harmful chemicals from the stomach. Low

enzyme activity (glycoside hydrolase and polysaccharide lipase) and poor

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 carbohydrate digestion/absorption in children with ASD can initiate the accumulation

of saccharides in the intestinal lumen, resulting into osmotic diarrhea, bloating, and

flatulence.

Recent research has shown that probiotics may help to improve bowel habits, behaviour, and

social functioning in autistic children. Disruption of the normal commensal microbial

community in humans has been associated with a growing number of disorders like

inflammatory intestinal disease and irritable bowel syndrome (IBS).

Most commonly used probiotic species include Bifid bacterium (bifidum, breve) and

Lactobacillus (acidophilus, casein). Lactobacillus reuteri has the capacity to restore gut

microbiota and behavioral abnormalities caused by maternal high fat diet. Though well-

designed, randomized, placebo-controlled clinical studies are necessary to establish the

efficacy of probiotics in the treatment of Autism spectrum disorder.

● Omega 3 and other supplements: omega-3 and omega-6 families are the two most

common classes of PUFA compounds. For the treatment of ASD, long-chain omega-3

polyunsaturated fatty acids (n-3 LCPUFA) are commonly used and thought to be

essential for brain development. Studies have reported that taking vitamin D along

with omega-3 polyunsaturated fatty acids supplements can help to reduce Autism

symptoms.

● SUBTRACTIVE APPROACH:

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 It focuses on eliminating certain foods/ food items from the diet. These foods are believed to

trigger allergies and food intolerance (for example, casein and gluten); and contribute to the

symptoms of Autism.

1. The GFCF diet: The Gluten Free Casein Free diet is used for children with ASD. This diet

aims to eliminate the usage of casein (dairy products) and gluten (wheat, barley, rye oats) in

the diet. Some children with ASD suffer from a "leaky gut", signifying abnormalities in

intestinal permeability that allow more significant components of proteins or peptides to be

absorbed directly; these peptides bind to opioid receptors in the brain and worsen symptoms

of ASD. Thus eliminating gluten and casein from the diet helps improve symptoms of

diseases in ASD.

This diet may include:

Oats

Orange/pineapple juice

White part of egg

Coconut water

Grapes/ pomegranate/avocado/banana/strawberry

Curd

Dry fruits (almonds, raisin)

Banana shake

Parboiled rice

Roasted chicken

Green vegetables

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 Salad

Multigrain flour

2. The Ketogenic diet: It is believed that autistic behaviours may result from abnormalities in

carbohydrate metabolism at the cellular level. Thus a diet high in fat, low in carbohydrates

and having regulated protein (GFCF) is found to cause symptoms of ASD. A ketogenic diet

often leads to poor growth, poor weight gain, and increased cholesterol levels, so it is

imperative to use this approach under the supervision of a registered dietician and

paediatrician.

3. Medium chain triglyceride diet (MCT) diet: it is an alternative type of ketogenic diet that

relies on the premise that medium-chain fatty acids such as octanoic acid (also known as

caprylic acid) and decanoic acid (also known as capric acid) are metabolized into ketone

bodies more efficiently and allow a more palatable diet with higher consumption of

carbohydrates. During an MCT diet, 30–60 percent of the calories are obtained from MCT oil

or emulsion and 30 percent from long-chain dietary fats. Though MCT diets are effective in

treating autism, there is a lack of clinical and preclinical studies available on autism.

Interestingly, case report followed a child with autism placed on a gluten-free, casein-free

MCT diet for several years and reported a remarkable reduction in the Childhood Autism

Rating Scale score from 49 to 17, representing a change from severe autism to non-autistic .

4. Monosaccharaides as dietary carbohydrates: As proposed earlier, abnormalities in

carbohydrate metabolism might add to symptoms of ASD. A diet based on

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 monosaccharaides, the simplest form of carbohydrates, is sometimes helpful. However, the

efficacy of using such a diet may be beneficial only in exceptional circumstances where

enzyme deficiency might be the reason for the symptoms of ASD.5.

5. Limit the processed foods and additives: Processed foods, artificial colours, flavours, and

preservatives can potentially worsen symptoms of Autism in some children. Try to minimise

these types of foods and opt for more natural, whole-food options instead.6.

6. Managing the nutrition diet for autistic kids requires patience, consistency, and attention to

their individual needs. Focusing on whole foods, addressing food sensitivities, and providing

structure and routine, can help support a child's overall health and well-being.

Strategies we can try:

If autistic child's diet is really poor, and we already addressed any sensory or physical issues,

we will need to address the behaviour of child first.

There are several approaches we can take:

 Use a behavioural approach: tell your child, "eat a bite of spinach and I'll give you a

prize," we may solve our child's eating problem. Rewards can work well, but this

approach can backfire if it's taken too far like, don't offer a toy for every bite of new

food, because this will make child dependent on prompts and rewards.

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 Find foods that are similar to their favourite ones: If child loves chicken nuggets,

chances are good they'll also enjoy chicken patties (a different shape). Child may also

be willing to try fish sticks (same shape and texture) or chicken fried steak. Similarly,

a child who likes apple sauce may be willing to try apple slices or apple pie.

 Offer options to child: For some children with and without autism, food is one of the

few areas where they feel they can exert control. Rather than getting into a power

struggle, offer child several food options and let them pick those they want to prefer.

Some parents use muffin tins to offer a smorgasbord of small acceptable possibilities.

 Write a short social story: Social stories are short stories, sometimes with

illustrations/ visual description, that you can write specifically to prepare child for

something new. You may write, like, "When it's dinner time, I sit at the table. There

are different foods on my plate. I must eat one bite of every food."

 Make healthy swaps for child: A whole wheat version of a favourite snack can up

its nutritional value, often without your child having to make a noticeable adjustment.

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In overall conclusion, while the relationship between autism and diet is complex and

multifaceted, there is growing evidence in support the idea that dietary interventions can play

a most significant role in supporting overall health and well-being in individuals with autism.

By focusing on nutrient-rich foods, incorporating probiotic-rich foods, and avoiding potential

triggers or allergens, individuals with autism may experience improvements in cognition,

behaviour, and digestive health.

It's important to remember that each individual with autism is unique, and consulting with the

healthcare professionals is very essential when making any significant changes to the

nutritional diet. With careful consideration and individualized approaches to diet, individuals

with autism can be supported in achieving their full potential.

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 REFERENCES

1. Overweight and obese status in children with autism spectrum disorder and disruptive

behavior. Criado KK, Sharp WG, McCracken CE, et al. Autism. 2018

2. Is there an overlap between eating disorders and neurodevelopmental disorders in

children with obesity? Wentz E, Björk A, Dahlgren J. Nutrients. 2019

74
3. Schreck K.A., Williams K., Smith A.F. A Comparison of Eating Behaviors Between

Children with and without Autism. J. Autism Dev. Disord. 2004.

4. The Association between Vitamin D Status and Autism Spectrum Disorder (ASD): A

Systematic Review and Meta-Analysis. Nutrients. 2020.

5. Egan AM, Dreyer ML, Odar CC, Beckwith M, Garrison CB: Obesity in young

children with autism spectrum disorders: prevalence and associated factors. Child

Obes. 2013

6. erywellhealth.com/connections-between-autism-and-nutrition-4155118

7. Christensen DL, Maenner MJ, Bilder D, et al.: Prevalence and characteristics of

autism spectrum disorder among children aged 4 years — Early Autism and

Developmental Disabilities Monitoring Network, seven sites, United States, 2010,

2012, and 2014. MMWR CDC Surveill Summ. 2019

8. Hill AP, Zuckerman KE, Fombonne E: Obesity and autism. Pediatrics. 2015

9. https://www.abtaba.com/blog/autism-diet

10. Catassi C, Bai JC, Bonaz B, et al.: Non-celiac gluten sensitivity: the new frontier of

gluten related disorders. Nutrients. 2013

11. Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA preschool forms

and profiles. Burlington, VT: University of Vermont Department of Psychiatry.

75
12. Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age

forms and profiles. Burlington, VT: University of Vermont, Research Center for

Children, Youth, and Families.

13. Autism Treatment Network. (2005). GI Symptom Inventory Questionnaire, vers. 3.0.

New York, NY: Autism Speaks.

14. https://www.hindustantimes.com/lifestyle/health/world-autism-awareness-day-2024-

9-nutrition-tips-for-children-with-autism-for-holistic-wellbeing

15. Baird, G., Charman, T., Pickles, A., Chandler, S., Loucas, T., Meldrum, D., Carcani-

Rathwell, I., Serkana, D., & Simonoff, E. (2008). Regression, developmental

trajectory and associated problems in disorders in the autism spectrum: the SNAP

study. Journal of Autism and Developmental Disorders, 38, 1827–1836.

16. Daniel Coury, M.D., medical director of Autism Speaks Autism Treatment Network.

17. R. Manikam and J. A. Perman, “Pediatric feeding disorders,” Journal of Clinical

Gastroenterology, vol. 30, no. 1, pp. 34–46, 2000.

18. World Health

Organisation.https://www.who.int/news-room/fact-sheets/detail/autismspectrum-

disorders. Accessed on 15th November 2022.

76
19. Adams, K. M., Lindell, K. C., Kohlmeier, M., & Zeisel, S. H. (2006). Status of

nutrition education in medical schools. The American Journal of Clinical Nutrition,

83(4)

20. Bandini, L.G., Anderson, S.E., Curtin, C., Cermak, S., Evans, E.W., Scampini, R.,

Maslin, M., Must, A. (2010). Food selectivity in children with autism spectrum

disorders and typically developing children. The Journal of Pediatrics, 157, 259-264

21. Happé F (2015) Autism as a neurodevelopmental disorder of mind-reading. Abstr

Book 3: 197–209.

22. Dover CJ, Le Couteur AL (2007) How to diagnose Autism. Arch Dis Child 92: 540–

545. doi: 10.1136/adc.2005.086280

23. Jukić V, Arbanas G (2013) Diagnostic and Statistical Manual of Mental Disorders;

Fifth Edition (DSM-5).Int J 57: 1546–1548.

24. Fombonne E (2009) Epidemiology of pervasive developmental disorders. Pediatr Res

65: 591–598. doi: 10.1203/PDR.0b013e31819e7203

25. Fombonne E, Quirke S, Hagen A (2009) Prevalence and interpretation of recent

trends in rates of pervasive developmental disorders. McGill J Med 12: 73.

26. Weintraub K (2011) Autism counts. Nature 479: 22–24. doi: 10.1038/479022a

27. Nazeer A, Ghaziuddin M (2012) Autism spectrum disorders: Clinical features and

diagnosis. Pediatr Clin North Am 59: 19–25. doi: 10.1016/j.pcl.2011.10.007

77
28. Zablotsky B, Black LI, Maenner MJ, et al. (2015) Estimated prevalence of autism and

other developmental disabilities following questionnaire changes in the 2014 national

health interview survey. Natl Health Stat Rep 2015: 1–20.

29. Hansen SN, Schendel DE, Parner ET (2015) Explaining the increase in the prevalence

of autism spectrum disorders the proportion attributable to changes in reporting

practices. JAMA Pediatr 169: 56–62. doi: 10.1001/jamapediatrics.2014.1893

30. Mostafa GA, ALayadhi LY (2012) Reduced serum concentrations of 25-hydroxy

vitamin D in children with autism: Relation to autoimmunity. J Neuroinflammation 9:

1–7.

31. Duan XY, Jia FY, Jiang HY (2013) Relationship between vitamin D and autism

spectrum disorder. Chin J Contemp Pediatr 15: 698–702.

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