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Dietary Intake and Parents' Perception of Mealtime Behaviors in Preschool-Age Children with Autism Spectrum Disorder and in Typically Developing Children
RESEARCH Research and Professional Briefs
Dietary Intake and Parents’ Perception of Mealtime Behaviors in Preschool-Age Children with Autism Spectrum Disorder and in Typically Developing Children DONNA W. LOCKNER, PhD, RD; TERRY K. CROWE, PhD; BETTY J. SKIPPER, PhD
ABSTRACT Parents of children with autism spectrum disorder (ASD) frequently report that their children have selective eating behaviors and refuse many foods, which could result in inadequate nutrient intake. This preliminary cross-sectional descriptive study investigated dietary intake and parents’ reported perception of food behaviors of 20 3- to 5-year-old children with ASD. Twenty typically developing children matched for sex, age, and ethnicity were also studied as a case-control comparison. Nutrient intake determined from 3-day food records was adjusted for dayto-day variation to determine the estimate of usual intake distribution for the two groups. This distribution was compared with the Estimated Average Requirement or Adequate Intake recommendations. The reported food behaviors and use of vitamin or mineral supplements were compared for matched pairs using the exact McNemar test. Nutrient intake was similar for both groups of children, with the majority of children consuming more than the recommended amounts for most nutrients. Nutrients least likely to be consumed in recommended amounts were vitamin A, vitamin E, fiber, and calcium. Children with ASD were more likely to consume vitamin/mineral supplements than typically developing children. Compared with parents of typically developing children, parents of children with ASD were more likely to report that their children were picky eaters and resisted trying new
D. W. Lockner is an associate professor, Nutrition Program, Department of Individual, Family, and Community Education, College of Education, University of New Mexico, Albuquerque. T. K. Crowe is a professor, Division of Occupational Therapy, Department of Pediatrics, and B. J. Skipper is a professor, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque. Address correspondence to: Donna W. Lockner, PhD, RD, Nutrition Program, College of Education, MSC05 3040, University of New Mexico, Albuquerque, NM 87131. E-mail: [email protected] Manuscript accepted: December 14, 2007. Copyright © 2008 by the American Dietetic Association. 0002-8223/08/10808-0008$34.00/0 doi: 10.1016/j.jada.2008.05.003
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foods, and they were less likely to describe their children as healthy eaters or that they eat a variety of foods. Despite the similar and generally adequate nutrient intake for the 40 children in this study, parents of children with ASD had more negative perceptions of their children’s dietary behaviors. J Am Diet Assoc. 2008;108:1360-1363.
C
hildren diagnosed with autism spectrum disorder (ASD) exhibit a variety of symptoms, including impairment in social interactions, impairment in communication, and restrictive, repetitive behavior (1). In addition, there are reports of children with ASD also having peculiar habits related to food and eating. Caregivers report that children with ASD like sameness of food items and have specific eating behaviors with more food preferences compared to typically developing children (2-6). It is sometimes noted that children with ASD have a strong preference for only one color food or only food in particular packaging and may refuse new foods or foods with certain textures (3-5). Whenever a child’s diet is limited in variety, the nutritional status of the child may be jeopardized due to inadequate intake of nutrients. Despite this concern, there are limited reports in the literature of studies on the nutritional intake of children with ASD. Two older studies report no difference in nutrient intake between children with ASD compared with children without ASD (2,7), whereas other studies show children with ASD had dietary intake less than the recommended amounts for vitamin C, vitamin D, several B vitamins, iron, and calcium (8) or intake containing fewer different foods within food group categories compared with children without ASD (6). The preschool years are characterized by slower growth than during infancy and the toddler years, yet this period of steady growth still requires adequate nutrients to allow for appropriate growth and development (9). Thus, because of the potential of limited nutrient intake due to food selectivity, this study examined nutrient intake from food for preschool children age 3 to 5 years who had been diagnosed with ASD. The objective of this cross-sectional descriptive pilot study was to compare the dietary intake of preschoolers with ASD to reference values; a group of matched typically developing children was also studied for a case-control comparison. Further, parental opinions
© 2008 by the American Dietetic Association
about food behaviors were also investigated to determine whether parents of preschoolers with ASD had a more negative perception of their children’s food habits than parents of typically developing children. Use of nonprescription vitamin/mineral supplements was also investigated, but not included in the nutrient analysis for either group. METHODS Parents of children between the ages of 3 and 5 years who had been diagnosed with ASD and referred to the University of New Mexico Center for Development and Disability between July 2003 and August 2005 were asked to participate in a study about mealtime behaviors. Parents were informed of a stipend ($50) that would be paid to families for participating. Nutrition was not specifically mentioned in the recruitment materials to avoid a bias toward families with more interest in nutrition. At the same time, to recruit typically developing children, flyers advertising the study were posted in medical offices and preschools in the metropolitan area surrounding the Center for Development and Disability. The recruitment materials for typically developing children also only mentioned mealtime behaviors and the stipend and did not specifically address nutrition. Only typically developing children who were reported by parents to have no delays in the areas of motor development, language development, or behavior and who matched enrolled children with ASD for age (within 6 months), sex, and ethnicity were enrolled in the study. All children with ASD who completed the mealtime behavior survey and 3-day food records (n⫽20) were included in the study. The University of New Mexico Human Research Review Committee approved this study. Procedures After determining eligibility, a research assistant contacted families and arranged a home visit at each family’s convenience. The research assistant, who had been trained by a registered dietitian in how to complete diet records, trained the parent to carefully fill out detailed food records. Parents were instructed to record all food and beverage intake for two weekdays and one weekend day that they considered typical for the child. The days did not need to be consecutive. At this same home visit, triceps skinfold measurements were taken for each child according to standardized procedures (10), and a survey of parental opinions of mealtime behaviors and supplement use was administered. Data Analysis Each food record was analyzed using Food Processor (version 8.22, 2003, ESHA, Salem, OR). Supplement data were not included on the food records; the nutrient analysis was based solely on dietary intake from food sources to better evaluate the adequacy of foods in the diet. If items consumed were not listed in the database, substitutions with similar nutrient values (based on comparison of food labels to database values) were selected by the registered dietitian, who completed the analysis of all records. At the time of analysis, the records were coded to
ensure the researcher did not know if the child had ASD or was typically developing. The usual intake distribution for nutrients for the children with ASD and typically developing children was adjusted for day-to-day variation using PC-SIDE computer software (version 1.02, 1997, Iowa State University Statistical Laboratory, Ames). For nutrients with a published Dietary Reference Intake Estimated Average Requirement (EAR), the probability of intake being less than the EAR was determined. The reference value for 4to 8-year-old children was used because the mean age for this sample was 52.4 months (4 years and 4 months). Group differences were compared for matched pairs using the Wilcoxon signed rank test for skinfold measurements and the exact McNemar test for family demographics and particular food behaviors. RESULTS AND DISCUSSION By the end of the 2-year recruitment period, 20 children with ASD had completed 3-day food records and the survey and were matched with 20 typically developing children. The participants were 6 girls and 34 boys with a mean age of 52.4 months. Ethnicity was 50% white, 45% Hispanic, and 5% Native American. Although not considered for matching purposes, there was no difference (P⬎0.05) between the children with ASD and typically developing children for family income, mother’s educational level, and mother’s marital status. Triceps skinfold measurement, used as a proxy for adiposity to help ensure the similarity of the groups, did not differ between groups (P⫽0.74) with a mean (⫾standard deviation) skinfold measurement of 11.4⫾3.3 mm for the children with ASD and 11.1⫾3.2 mm for typically developing children. Table 1 shows the median (⫾standard error [SE]) and percentage less than the EAR for selected nutrients for the two groups. For most nutrients, there was a low percentage of children consuming less than the EAR for both groups of children. Vitamin E and vitamin A were the nutrients most likely to be consumed in low amounts. Low intake of vitamin E has been noted in other studies of children from infancy through adolescence (11-14) and is not specific to children with ASD. Although there is a recent report of clinically determined suboptimal vitamin E status in a small group of preschool children (13), a low level of plasma vitamin E has not been noted as a widespread problem (15). It also may be possible that the actual intake of vitamin E is more, but the database for computerized diet analysis is missing some values for this nutrient. Therefore, the clinical and practical application of the low intakes of vitamin E noted here is not known. For vitamin A, 52.7% of the children with ASD had an intake less than the EAR, whereas 20.4% of typically developing children’s intake was less than the EAR. It is likely that vitamin A intake could be increased for many preschool children for optimal health. For the two nutrients analyzed in this study that do not have an EAR value established— calcium and fiber—the assessment of the adequacy of intake is limited. These nutrients have a published Adequate Intake (AI), and due to the method by which the AI is established, it is not possible to determine the prevalence of inadequacy (16). The AI for calcium for the group studied is 800 mg, and the median intake (⫾SE) (adjusted for day-to-day varia-
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Table 1. Comparison of nutrient intake from food sources between preschool age children with autism spectrum disorder (n⫽20) and typically developing children (n⫽20) MedianⴞSEa
Nutrient Protein (g) Children with ASDc Typically developing Carbohydrate (g) Children with ASD Typically developing Vitamin A (g) Children with ASD Typically developing Folate (g) Children with ASD Typically developing Vitamin B-6 (mg) Children with ASD Typically developing Vitamin C (mg) Children with ASD Typically developing Vitamin E (mg) Children with ASD Typically developing Iron (mg) Children with ASD Typically developing
% Below EARb
children
46.4⫾3.98 55.5⫾3.98
0 0
children
196⫾16.4 201⫾13.4
2.0 1.0
children
261⫾59.6 382⫾65.8
52.7 20.4
children
171⫾23.9 206⫾23.1
29.4 22.5
children
0.86⫾0.12 0.85⫾0.12
6.9 12.7
children
56⫾16.6 67⫾13.1
15.1 4.0
children
2.9⫾0.59 2.8⫾0.54
85.7 92.9
children
8.9⫾1.10 9.9⫾1.24
0.5 0.4
a
SE⫽standard error. EAR⫽Estimated Average Requirement for children 4-8 years of age. ASD⫽autism spectrum disorder.
b c
tion) was 658⫾93.7 mg for the children with ASD and 827⫾79.3 mg for typically developing children. For fiber, the median intake (⫾SE) for both groups was less than the AI of 25 g: 10.4⫾1.32 g for children with ASD and 9.6⫾0.85 g for typically developing children. It is interesting to note that analysis of the food records for both groups of children revealed similar nutrient intake from food sources and intakes close to or exceeding recommended amounts for many nutrients, yet parents of children with ASD had a more negative opinion of their children’s diets and food behaviors (Table 2). Compared with parents of typically developing children, parents of children with ASD were more likely to report children having favorite food textures, resisting trying new foods, and being picky eaters; and less likely to describe their children as eating a variety of foods. Parents of typically developing children were more likely to describe their children as healthy eaters compared with parents of children with ASD. Parents who are overly concerned about the nutritional adequacy of the children’s diets may place undue emphasis on food intake and mealtime behavior at the expense of more relaxed mealtimes and family dynamics (17). Despite the more negative perceptions of the parents of children with ASD, results of nutrient intake from this small study are in agreement with those of Carruth and colleagues (18), who found that younger children de-
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Table 2. Comparison of number of parents of children with autism spectrum disorder and parents of typically developing children who report particular food behaviors for their children
Dietary behavior
Parents of children with ASDa (nⴝ19)
Has favorite food textures 13 Picky eaterb 15 Resists trying new foods 18 Healthy eaterb 2 Eats of variety of foods 3 Limits intake to favorite colors 1
Parents of typically developing P children (nⴝ19) value 1 3 9 11 11 1
⬍0.001 0.002 0.01 0.01 0.04 —
a
ASD⫽autism spectrum disorder. The terms picky eater and healthy eater were not further defined for parents and were therefore subject to parental interpretation. b
scribed as picky eaters had dietary intakes equal to or exceeding recommendations. Therefore, although there are many challenging aspects of raising a child with ASD, perhaps results of this study will help reassure parents of children with ASD and encourage them to prevent food from becoming an issue that could potentially disrupt family mealtimes. There were 12 children (60%) with ASD regularly taking nonprescription vitamin/mineral supplements, while only five (25%) of the typically developing children did so. Of those children with ASD who consumed supplements, three exceeded the 40 mg Tolerable Upper Intake Level (UL) for vitamin B-6 with a maximum of 225 mg/day. One child with ASD exceeded the UL for magnesium of 110 mg with a reported intake of 173 mg/day. No other supplement intake exceeded any UL. No child who was typically developing exceeded the UL for any nutrient. Supplement use has been reported to be higher for children when parents report increased levels of food selectivity or food refusal (19). Parents of children with ASD in this study were more likely to describe their child as a “picky eater,” resisting trying new foods, and not as eating a variety of foods or as a “healthy eater.” These factors may explain the higher rate of supplement use by children with ASD despite adequate dietary intake. A surprising finding of this study was that there was only one parent of a child with ASD who reported that the child limited intake of foods based on color. Interestingly, there was also one parent of a typically developing child who also reported that the child limited intake of foods based on color. Anecdotal reports of children with ASD having a preference for foods of only one color may be accurate, but limited to a small number of children, with some typically developing children also exhibiting this selective behavior. A limitation of this pilot study is that all dietary information for each child was based on parental reports and some record-keeping by child-care providers; therefore, it may not be an accurate representation of the child’s actual diet. The extensive training for parents on the appropriate method for recording dietary intake was in-
tended to yield the best possible representation of the actual diets of children, but the inherent problems of recording dietary intake, such as inaccurate measurement of the portion consumed or modification of the usual intake because of the burden of record-keeping (20), cannot be ignored. In addition, statistical comparison of nutrient intake from food sources between groups of children was not explored because the small sample size limited statistical power. CONCLUSIONS Results of this study of 40 preschool children indicate that the majority of these children were consuming a diet adequate in most nutrients, regardless of whether the children were diagnosed with ASD or were developing normally. Although there were some nutrients that were consumed below recommended amounts, these were similar for children with ASD and typically developing children. The results of this study may be considered preliminary due to the limited sample size, but should help reassure parents and nutrition professionals that preschool-age children with ASD are likely to have dietary intake similar to typically developing children. Parents should be encouraged to view the positive aspects of their children’s diets and strive for an enjoyable mealtime experience for all family members. This research was supported by a University of New Mexico School of Medicine Research Allocation Committee grant. The authors acknowledge the contributions of Sarah Picchiarini, MOT, OTR/L; Catherine McClain, MD, PT; Patricia Osborne, MA, CCC, CED; Beth Provost, PhD, PT; Kaylyn Acree, MOT, OTR/L; Paul Regalato, MPT, PT; and the parents and children who participated in this study. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington, VA: American Psychiatric Association; 2000.
2. Raiten DJ, Massaro T. Perspectives on the nutritional ecology of autistic children. J Autism Dev Disord. 1986;16:133-142. 3. Ahern WH, Castine T, Nault K, Green G. An assessment of food acceptance in children with austism or pervasive developmental disorder-not otherwise specified. J Autism Dev Disord. 2001;31:505-511. 4. Cornish E. Gluten and casein free diets in autism: A study of the effects on food choice and nutrition. J Hum Nutr Diet. 2002;15:261269. 5. Williams PG, Dalrymple N, Neal J. Eating habits of children with autism. Pediatr Nurs. 2000;26:259-274. 6. Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without autism. J Autism Dev Disord. 2004;34:433-438. 7. Shearer TR, Larson K, Neuschwander J, Gedney B. Minerals in the hair and nutrient intake of autistic children. J Autism Dev Disord. 1982;12:25-34. 8. Cornish E. A balanced approach towards healthy eating in autism. J Hum Nutr Diet. 1998;11:501-509. 9. Story M, Holt K, Sofka D, eds. Bright Futures in Practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2002. 10. Heyward VH, Wagner DR. Applied Body Composition Assessment. 2nd ed. Champaign, IL: Human Kinetics; 2004. 11. Devaney B, Ziegler P, Pac S, Karwe V, Barr SI. Nutrient intakes of infants and toddlers. J Am Diet Assoc. 2004;104(suppl 1):S14-S21. 12. Suitor CW, Gleason PM. Using dietary reference intake-based methods to estimate the prevalence of inadequate nutrient intake among school-aged children. J Am Diet Assoc. 2002;102:530-536. 13. Drewel BT, Giraud DW, Davy SR, Driskell JA. Less than adequate vitamin E status observed in a group of preschool boys and girls living in the United States. J Nutr Biochem. 2006;17:132-138. 14. Skinner JD, Carruth BR, Houck KS, Bounds W, Morris M, Cox DR, Moran J, Coletta F. Longitudinal study of nutrient and food intakes of white preschool children aged 24 to 60 months. J Am Diet Assoc. 1999;99:1514-1521. 15. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academies Press; 2000. 16. Barr SI, Murphy SP, Poos MI. Interpreting and using the Dietary Reference Intakes in dietary assessment of individuals and groups. J Am Diet Assoc. 2002;102:780-788. 17. Finney JW. Preventing common feeding problems in infants and young children. Pediatr Clin North Am. 1986;33:775-788. 18. Carruth BR, Ziegler PJ, Gordon A, Barr SI. Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering a new food. J Am Diet Assoc. 2004;102(suppl 1):S57-S64. 19. Yu SM, Kogan MD, Gergen P. Vitamin-mineral supplement use among preschool children in the United States. Pediatrics. 1997; 100:e4. 20. Rebro SM, Patterson RE, Kristal AR, Cheney CL. The effect of keeping food records on eating patterns. J Am Diet Assoc. 1998;98:11631165.
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Dietary Intake and Parents’ Perception of Mealtime Behaviors in Preschool-Age Children with Autism Spectrum Disorder and in Typically Developing Children DONNA W. LOCKNER, PhD, RD; TERRY K. CROWE, PhD; BETTY J. SKIPPER, PhD
ABSTRACT Parents of children with autism spectrum disorder (ASD) frequently report that their children have selective eating behaviors and refuse many foods, which could result in inadequate nutrient intake. This preliminary cross-sectional descriptive study investigated dietary intake and parents’ reported perception of food behaviors of 20 3- to 5-year-old children with ASD. Twenty typically developing children matched for sex, age, and ethnicity were also studied as a case-control comparison. Nutrient intake determined from 3-day food records was adjusted for dayto-day variation to determine the estimate of usual intake distribution for the two groups. This distribution was compared with the Estimated Average Requirement or Adequate Intake recommendations. The reported food behaviors and use of vitamin or mineral supplements were compared for matched pairs using the exact McNemar test. Nutrient intake was similar for both groups of children, with the majority of children consuming more than the recommended amounts for most nutrients. Nutrients least likely to be consumed in recommended amounts were vitamin A, vitamin E, fiber, and calcium. Children with ASD were more likely to consume vitamin/mineral supplements than typically developing children. Compared with parents of typically developing children, parents of children with ASD were more likely to report that their children were picky eaters and resisted trying new
D. W. Lockner is an associate professor, Nutrition Program, Department of Individual, Family, and Community Education, College of Education, University of New Mexico, Albuquerque. T. K. Crowe is a professor, Division of Occupational Therapy, Department of Pediatrics, and B. J. Skipper is a professor, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque. Address correspondence to: Donna W. Lockner, PhD, RD, Nutrition Program, College of Education, MSC05 3040, University of New Mexico, Albuquerque, NM 87131. E-mail: [email protected] Manuscript accepted: December 14, 2007. Copyright © 2008 by the American Dietetic Association. 0002-8223/08/10808-0008$34.00/0 doi: 10.1016/j.jada.2008.05.003
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foods, and they were less likely to describe their children as healthy eaters or that they eat a variety of foods. Despite the similar and generally adequate nutrient intake for the 40 children in this study, parents of children with ASD had more negative perceptions of their children’s dietary behaviors. J Am Diet Assoc. 2008;108:1360-1363.
C
hildren diagnosed with autism spectrum disorder (ASD) exhibit a variety of symptoms, including impairment in social interactions, impairment in communication, and restrictive, repetitive behavior (1). In addition, there are reports of children with ASD also having peculiar habits related to food and eating. Caregivers report that children with ASD like sameness of food items and have specific eating behaviors with more food preferences compared to typically developing children (2-6). It is sometimes noted that children with ASD have a strong preference for only one color food or only food in particular packaging and may refuse new foods or foods with certain textures (3-5). Whenever a child’s diet is limited in variety, the nutritional status of the child may be jeopardized due to inadequate intake of nutrients. Despite this concern, there are limited reports in the literature of studies on the nutritional intake of children with ASD. Two older studies report no difference in nutrient intake between children with ASD compared with children without ASD (2,7), whereas other studies show children with ASD had dietary intake less than the recommended amounts for vitamin C, vitamin D, several B vitamins, iron, and calcium (8) or intake containing fewer different foods within food group categories compared with children without ASD (6). The preschool years are characterized by slower growth than during infancy and the toddler years, yet this period of steady growth still requires adequate nutrients to allow for appropriate growth and development (9). Thus, because of the potential of limited nutrient intake due to food selectivity, this study examined nutrient intake from food for preschool children age 3 to 5 years who had been diagnosed with ASD. The objective of this cross-sectional descriptive pilot study was to compare the dietary intake of preschoolers with ASD to reference values; a group of matched typically developing children was also studied for a case-control comparison. Further, parental opinions
© 2008 by the American Dietetic Association
about food behaviors were also investigated to determine whether parents of preschoolers with ASD had a more negative perception of their children’s food habits than parents of typically developing children. Use of nonprescription vitamin/mineral supplements was also investigated, but not included in the nutrient analysis for either group. METHODS Parents of children between the ages of 3 and 5 years who had been diagnosed with ASD and referred to the University of New Mexico Center for Development and Disability between July 2003 and August 2005 were asked to participate in a study about mealtime behaviors. Parents were informed of a stipend ($50) that would be paid to families for participating. Nutrition was not specifically mentioned in the recruitment materials to avoid a bias toward families with more interest in nutrition. At the same time, to recruit typically developing children, flyers advertising the study were posted in medical offices and preschools in the metropolitan area surrounding the Center for Development and Disability. The recruitment materials for typically developing children also only mentioned mealtime behaviors and the stipend and did not specifically address nutrition. Only typically developing children who were reported by parents to have no delays in the areas of motor development, language development, or behavior and who matched enrolled children with ASD for age (within 6 months), sex, and ethnicity were enrolled in the study. All children with ASD who completed the mealtime behavior survey and 3-day food records (n⫽20) were included in the study. The University of New Mexico Human Research Review Committee approved this study. Procedures After determining eligibility, a research assistant contacted families and arranged a home visit at each family’s convenience. The research assistant, who had been trained by a registered dietitian in how to complete diet records, trained the parent to carefully fill out detailed food records. Parents were instructed to record all food and beverage intake for two weekdays and one weekend day that they considered typical for the child. The days did not need to be consecutive. At this same home visit, triceps skinfold measurements were taken for each child according to standardized procedures (10), and a survey of parental opinions of mealtime behaviors and supplement use was administered. Data Analysis Each food record was analyzed using Food Processor (version 8.22, 2003, ESHA, Salem, OR). Supplement data were not included on the food records; the nutrient analysis was based solely on dietary intake from food sources to better evaluate the adequacy of foods in the diet. If items consumed were not listed in the database, substitutions with similar nutrient values (based on comparison of food labels to database values) were selected by the registered dietitian, who completed the analysis of all records. At the time of analysis, the records were coded to
ensure the researcher did not know if the child had ASD or was typically developing. The usual intake distribution for nutrients for the children with ASD and typically developing children was adjusted for day-to-day variation using PC-SIDE computer software (version 1.02, 1997, Iowa State University Statistical Laboratory, Ames). For nutrients with a published Dietary Reference Intake Estimated Average Requirement (EAR), the probability of intake being less than the EAR was determined. The reference value for 4to 8-year-old children was used because the mean age for this sample was 52.4 months (4 years and 4 months). Group differences were compared for matched pairs using the Wilcoxon signed rank test for skinfold measurements and the exact McNemar test for family demographics and particular food behaviors. RESULTS AND DISCUSSION By the end of the 2-year recruitment period, 20 children with ASD had completed 3-day food records and the survey and were matched with 20 typically developing children. The participants were 6 girls and 34 boys with a mean age of 52.4 months. Ethnicity was 50% white, 45% Hispanic, and 5% Native American. Although not considered for matching purposes, there was no difference (P⬎0.05) between the children with ASD and typically developing children for family income, mother’s educational level, and mother’s marital status. Triceps skinfold measurement, used as a proxy for adiposity to help ensure the similarity of the groups, did not differ between groups (P⫽0.74) with a mean (⫾standard deviation) skinfold measurement of 11.4⫾3.3 mm for the children with ASD and 11.1⫾3.2 mm for typically developing children. Table 1 shows the median (⫾standard error [SE]) and percentage less than the EAR for selected nutrients for the two groups. For most nutrients, there was a low percentage of children consuming less than the EAR for both groups of children. Vitamin E and vitamin A were the nutrients most likely to be consumed in low amounts. Low intake of vitamin E has been noted in other studies of children from infancy through adolescence (11-14) and is not specific to children with ASD. Although there is a recent report of clinically determined suboptimal vitamin E status in a small group of preschool children (13), a low level of plasma vitamin E has not been noted as a widespread problem (15). It also may be possible that the actual intake of vitamin E is more, but the database for computerized diet analysis is missing some values for this nutrient. Therefore, the clinical and practical application of the low intakes of vitamin E noted here is not known. For vitamin A, 52.7% of the children with ASD had an intake less than the EAR, whereas 20.4% of typically developing children’s intake was less than the EAR. It is likely that vitamin A intake could be increased for many preschool children for optimal health. For the two nutrients analyzed in this study that do not have an EAR value established— calcium and fiber—the assessment of the adequacy of intake is limited. These nutrients have a published Adequate Intake (AI), and due to the method by which the AI is established, it is not possible to determine the prevalence of inadequacy (16). The AI for calcium for the group studied is 800 mg, and the median intake (⫾SE) (adjusted for day-to-day varia-
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Table 1. Comparison of nutrient intake from food sources between preschool age children with autism spectrum disorder (n⫽20) and typically developing children (n⫽20) MedianⴞSEa
Nutrient Protein (g) Children with ASDc Typically developing Carbohydrate (g) Children with ASD Typically developing Vitamin A (g) Children with ASD Typically developing Folate (g) Children with ASD Typically developing Vitamin B-6 (mg) Children with ASD Typically developing Vitamin C (mg) Children with ASD Typically developing Vitamin E (mg) Children with ASD Typically developing Iron (mg) Children with ASD Typically developing
% Below EARb
children
46.4⫾3.98 55.5⫾3.98
0 0
children
196⫾16.4 201⫾13.4
2.0 1.0
children
261⫾59.6 382⫾65.8
52.7 20.4
children
171⫾23.9 206⫾23.1
29.4 22.5
children
0.86⫾0.12 0.85⫾0.12
6.9 12.7
children
56⫾16.6 67⫾13.1
15.1 4.0
children
2.9⫾0.59 2.8⫾0.54
85.7 92.9
children
8.9⫾1.10 9.9⫾1.24
0.5 0.4
a
SE⫽standard error. EAR⫽Estimated Average Requirement for children 4-8 years of age. ASD⫽autism spectrum disorder.
b c
tion) was 658⫾93.7 mg for the children with ASD and 827⫾79.3 mg for typically developing children. For fiber, the median intake (⫾SE) for both groups was less than the AI of 25 g: 10.4⫾1.32 g for children with ASD and 9.6⫾0.85 g for typically developing children. It is interesting to note that analysis of the food records for both groups of children revealed similar nutrient intake from food sources and intakes close to or exceeding recommended amounts for many nutrients, yet parents of children with ASD had a more negative opinion of their children’s diets and food behaviors (Table 2). Compared with parents of typically developing children, parents of children with ASD were more likely to report children having favorite food textures, resisting trying new foods, and being picky eaters; and less likely to describe their children as eating a variety of foods. Parents of typically developing children were more likely to describe their children as healthy eaters compared with parents of children with ASD. Parents who are overly concerned about the nutritional adequacy of the children’s diets may place undue emphasis on food intake and mealtime behavior at the expense of more relaxed mealtimes and family dynamics (17). Despite the more negative perceptions of the parents of children with ASD, results of nutrient intake from this small study are in agreement with those of Carruth and colleagues (18), who found that younger children de-
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Table 2. Comparison of number of parents of children with autism spectrum disorder and parents of typically developing children who report particular food behaviors for their children
Dietary behavior
Parents of children with ASDa (nⴝ19)
Has favorite food textures 13 Picky eaterb 15 Resists trying new foods 18 Healthy eaterb 2 Eats of variety of foods 3 Limits intake to favorite colors 1
Parents of typically developing P children (nⴝ19) value 1 3 9 11 11 1
⬍0.001 0.002 0.01 0.01 0.04 —
a
ASD⫽autism spectrum disorder. The terms picky eater and healthy eater were not further defined for parents and were therefore subject to parental interpretation. b
scribed as picky eaters had dietary intakes equal to or exceeding recommendations. Therefore, although there are many challenging aspects of raising a child with ASD, perhaps results of this study will help reassure parents of children with ASD and encourage them to prevent food from becoming an issue that could potentially disrupt family mealtimes. There were 12 children (60%) with ASD regularly taking nonprescription vitamin/mineral supplements, while only five (25%) of the typically developing children did so. Of those children with ASD who consumed supplements, three exceeded the 40 mg Tolerable Upper Intake Level (UL) for vitamin B-6 with a maximum of 225 mg/day. One child with ASD exceeded the UL for magnesium of 110 mg with a reported intake of 173 mg/day. No other supplement intake exceeded any UL. No child who was typically developing exceeded the UL for any nutrient. Supplement use has been reported to be higher for children when parents report increased levels of food selectivity or food refusal (19). Parents of children with ASD in this study were more likely to describe their child as a “picky eater,” resisting trying new foods, and not as eating a variety of foods or as a “healthy eater.” These factors may explain the higher rate of supplement use by children with ASD despite adequate dietary intake. A surprising finding of this study was that there was only one parent of a child with ASD who reported that the child limited intake of foods based on color. Interestingly, there was also one parent of a typically developing child who also reported that the child limited intake of foods based on color. Anecdotal reports of children with ASD having a preference for foods of only one color may be accurate, but limited to a small number of children, with some typically developing children also exhibiting this selective behavior. A limitation of this pilot study is that all dietary information for each child was based on parental reports and some record-keeping by child-care providers; therefore, it may not be an accurate representation of the child’s actual diet. The extensive training for parents on the appropriate method for recording dietary intake was in-
tended to yield the best possible representation of the actual diets of children, but the inherent problems of recording dietary intake, such as inaccurate measurement of the portion consumed or modification of the usual intake because of the burden of record-keeping (20), cannot be ignored. In addition, statistical comparison of nutrient intake from food sources between groups of children was not explored because the small sample size limited statistical power. CONCLUSIONS Results of this study of 40 preschool children indicate that the majority of these children were consuming a diet adequate in most nutrients, regardless of whether the children were diagnosed with ASD or were developing normally. Although there were some nutrients that were consumed below recommended amounts, these were similar for children with ASD and typically developing children. The results of this study may be considered preliminary due to the limited sample size, but should help reassure parents and nutrition professionals that preschool-age children with ASD are likely to have dietary intake similar to typically developing children. Parents should be encouraged to view the positive aspects of their children’s diets and strive for an enjoyable mealtime experience for all family members. This research was supported by a University of New Mexico School of Medicine Research Allocation Committee grant. The authors acknowledge the contributions of Sarah Picchiarini, MOT, OTR/L; Catherine McClain, MD, PT; Patricia Osborne, MA, CCC, CED; Beth Provost, PhD, PT; Kaylyn Acree, MOT, OTR/L; Paul Regalato, MPT, PT; and the parents and children who participated in this study. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington, VA: American Psychiatric Association; 2000.
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