Three Most Common Questions a WIC Nutritionist is

Three Most Common Questions a WIC Nutritionist is Asked & How to Handle Them Elizabeth Strickland, MS, RD, LD PO Box 3297 Glen Rose, TX 76043 Telephone: (830) 237 -2886 Fax: (866) 855 -8301 Email: ASDpuzzle@aol. com Website: www. ASDpuzzle. com BOOK: EATING FOR AUTISM

Three Most Common Questions a WIC Nutritionist is Asked & How to Handle Them AUTISM l Should I put my child on the Gluten Free Casein Free Diet? l What nutritional supplements should I give my child? l My child is a picky eater how can I expand his diet?

What is Autism? Autism Spectrum Disorder 299. 00 Autistic Disorder 299. 80 Asperger’s Disorder 299. 80 Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) American Psychiatric Association

Autism Spectrum Disorder ASD l l l Puzzling childhood disorder 1 in 88 children 1 in 54 boys Affects communication, social interaction and behavior Spectrum disorder

Should I put my child on the GFCF Diet? Elimination Diets common in the autism community: Gluten Free Casein Free Diet (GFCF) Others: l Specific Carbohydrate Diet (SCD) l Gut & Psychology Syndrome Diet (GAPS) l Rotation l Antifungal l Feingold l Low Oxalate

Gluten Free Casein Free Diet l The GFCF Diet is the single most common Elimination/Challenge diet recommended for children with autism. l There is very little evidence-based scientific research that supports or refutes claims of the GFCF Diet.

Gluten Free Casein Free Diet Ongoing Research: “Diet and Behavior in Young Children with Autism. ” Sponsor: National Institute of Mental Health Clinical Trials Identifier: NCT 00090428 “A Study to Assess the Role of a GFCF Diet in the Dietary Management of Autism Associated Gastrointestinal Disorders. ” Sponsor: Massachusetts General Hospital Clinical Trials Identifier: NCT 01116388 Website: www. clinicaltrials. gov

Gluten Free Casein Free Diet Positive results reported by parents: l Improves gastrointestinal symptoms l Decreases hyperactivity l Increases focus l Reduces behavioral problems l Improves speech & communication skills l Improves sleep

Gluten Free Casein Free Diet Gluten is the protein found in: Common food products to avoid: l Wheat l Barley l Rye l l l l Bran Couscous Cream of wheat Farina Kamut Malt Matzo/matzoh meal Oats and oatmeal Pasta Seitan Semolina Splet Tabbouleh Tritical Udon Wheat germ, flour, and starch

Gluten Free Casein Free Diet Food additives may contain gluten: l l l l l Emulsifiers Fillers Flavoring Hydrolyzed vegetable protein Texturized vegetable protein Modified food starch Seasonings Stabilizers Vegetable protein Nonfood sources of gluten: l Over the counter medications l Vitamin mineral supplements l Lipstick, lip gloss, & lip balms l Play-Doh l Glue

Gluten Free Casein Free Diet Casein is the protein found in: Common foods to avoid: l Cow’s l l l l l milk products Cow’s milk Butter Caseinates Cheese and cottage cheese Cream Curds Custard and pudding Ghee Goat’s milk Half & Half Ice Cream, Ice Milk, & Sherbet Lactoglobulin, Lactalbumin, Lactoferrin Milk chocolate Nougat Rennet Sour cream Whey Yogurt

Gluten Free Casein Free Diet Food products and additives that may contain casein: l l l l Brown sugar flavoring Canned tuna Caramel flavoring Chocolate Commercially prepared mixes Lactic acid starter culture Margarine Packaged dinners Processed meats (hot dogs, luncheon, and sausage) Natural flavoring Nondairy creamer Salad dressings Sauces and soups Simplesse Vegetarian nondairy cheese substitutes Whipped topping

Gluten Free Casein Free Diet Should I put my child on the GFCF Diet? “Clinical observation and anecdotal reporting warrants a case-by-case consideration for a GFCF Diet trial response. ” Elizabeth Strickland, MS, RD, LD

My Child is a Picky Eater How Can I Expand His Diet?

Picky Eater vs. Problem Feeder Mealtime myths: “He’ll eat when he gets hungry enough. Kids won’t starve themselves. ” “Don’t worry, he’ll outgrow his picky eating stage. ” This is NOT true for most autistic children who have a feeding problem as opposed to a typical developing child who is a picky eater.

Picky Eater vs. Problem Feeder Picky Eater l l l Decreased variety of food (< 30 foods). Foods lost due to burnout regained after 2 wks. Able to tolerate new foods on plate, touch, or taste. Eats at least 1 food from most food textures. Adds new foods to repertoire in 15 -25 steps. Problem Feeder l l l Restricted range of foods (< 20 foods). Foods lost due to burnout, foods not regained. “Falls apart” when presented new foods. Refuses entire categories of textures. Adds new foods in > 25 steps. Kay Toomey, Ph. D.

Feeding Problem “The prevalence of problem eating behaviors in children with autism has been estimated to range between 46% and 89%. ” Feeding problems in children with autism spectrum disorders: a review. Focus Autism Other Dev Disabil. 2006; 21(3): 153 -166.

Feeding Problem Common Mealtime Behaviors in Children with ASD: Selective food refusal 2. Food neophobia (fear of trying unfamiliar 1. foods) Nonfunctional mealtime rituals 4. Tantrums 3.

Feeding Problem Contributing Factors: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Medical Psychological Nutritional Oral-Motor Dysfunction Sensory Processing Disorder Environmental Child Parent Therapist Behavioral

Feeding Problem Basic Mealtime Strategies l l l l Do NOT allow child to “graze” 3 meals + 3 snacks per day Limit juice, milk, beverages to appropriate amounts Avoid distractions during mealtime Practice “social modeling” Offer manageable foods Positive reinforcement Use appropriate mealtime language

Feeding Problem Basic Mealtime Strategies l l l Prevent food repetition and burn-out Change one property of the same food each time offered Expose child to a non-preferred food on a daily basis Do NOT bribe, beg, or force child to “take a bite” Limit mealtime to less than 30 minutes Keep meal & snack times a pleasant atmosphere

Feeding Problem Feeding Therapy 1. Feeding Team 2. Physician Registered Dietitian Behavioral Specialist Occupational Therapist l Speech Language Pathologist l l 3. 4. 5. Build a multidisciplinary Feeding Team Individual team members complete an assessment List of the contributing factors Develop a Feeding Intervention Plan Implement the feeding therapy sessions

Feeding Therapy What feeding methods are NOT helpful? Mere exposure to food 2. Food Deprivation 1. Research supports that mere exposure to food will increase food preference among typically developing children; however, no studies support this technique is effective for treating children with feeding problems.

Feeding Therapy What feeding methods are helpful? A combination of feeding methods varying for each child based on their individual feeding problems. l Building on preferred foods l Behavioral l Sensory

SOS Approach to Eating Steps to eating: 1. 2. 3. 4. 5. 6. Tolerate Interact Smell Touch Taste Eating SOS Approach to Eating Kay Toomey, Ph. D. Pediatric Psychologist

Feeding Problem l l l Eating is one of the most important and complex skills acquired in early childhood. Children with ASD typically have problems with feeding. Feeding problems may lead to malnutrition negatively impacting brain and body function. A multi-disciplinary approach to assessing and treating the feeding problem is critical. The feeding treatment methods should be individualized for each child.

What nutritional supplements should I give my child? “There are numerous vitamins, minerals, antioxidants, amino acids, nutraceuticals and herbs believed to benefit children with ASD. These supplements are accepted and commonly used as advanced nutritional interventions in the autism community; however, the medical community may not support their use. ” Elizabeth Strickland, MS, RD, LD

Nutritional Supplements This situation is NOT appropriate!!! Lost Causes No More Alternative Medicine September 2004 Issue 70 Melanie Haiken Photography by Arthur Cohen

Vitamin Mineral Supplement “Most U. S. children do not receive adequate nutrition through their diet and children with ASD have additional nutritional concerns. Adding a daily multi vitamin and mineral supplement to the autistic child’s treatment plan is warranted. ” Elizabeth Strickland, MS, RD, LD

Vitamin Mineral Supplement Children with ASD are at increased nutritional risk: l Sensory problems l Consume a limited variety of foods l Mealtime behavior problems l Elimination diets that limit certain foods l Chronic gastrointestinal disorders

Vitamin Mineral Supplement Subclinical Nutrition Deficiency A deficiency of a particular vitamin or mineral that is not severe enough to produce a classic deficiency symptom but rather has more global, subtle effects that result in loss of optimal health and impairment of body processes.

Vitamin Mineral Supplement Nutrient Deficiency Stages 1 st Preliminary → Depletion of tissue stores 2 nd Biochemical → Reduced enzyme activity 3 rd Physiologic/Behavior → Subclinical deficiency symptoms 4 th Clinical → Symptoms worsen 5 th Anatomical → Specific syndromes The Essential Guide to Vitamins and Minerals Elizabeth Somer, MA, RD

Vitamin Mineral Supplement Subclinical nutrition deficiency symptoms: l Irritability l Mood and behavior changes l Poor concentration l Depression l Anxiety l Sleep disturbances l Loss of appetite

Vitamin Mineral Supplement Selection of a V/M supplement: l Buy from a reputable company Examples: § Kirkman® www. kirkmangroup. com § Village Green Apothecary www. myvillagegreen. com

Vitamin Mineral Supplement Selection of a V/M supplement: l Quality § § § Control Procedures US Pharmacopeia (USP) Consumer Lab NSF International

Vitamin Mineral Supplement Selection of a V/M supplement: l Read the label Avoid: § Artificial colors and flavors § Potential allergens (wheat, milk, soy, egg, corn) § Herbs

Vitamin Mineral Supplement Selection of a V/M supplement: l Full § § spectrum vitamins & minerals Fat soluble vitamins (A, D, E, K) Vitamin B complex (B 1, B 2, B 3, B 5, B 6, B 12, folic acid, biotin) Vitamin C Minerals (calcium, magnesium, zinc, selenium, manganese, chromium, molybdenum) l 100 – 300% RDA

Vitamin Mineral Supplement Approaches to get child to take supplement: 1. 2. 3. 4. 5. Incorporate into child’s Behavior Therapy Program Oralflo pill swallowing cup Pill Swallow Program Negotiation Mix supplement into food or beverage Book: “Eating for Autism”, Chapter 3 Elizabeth Strickland, MS, RD, LD

Vitamin Mineral Supplement Mix in: l l l l Beverages Juice box Fruit smoothie Fruit sorbet Rice dream Yogurt, pudding, custard Peanut butter Fruit preserves Honey Ketchup Cooked foods (after cooking) Popsicles (homemade) Coromega®

Omega-3 Fatty Acids Supplement “Most U. S. children do not consume an adequate amount of Omega-3 fatty acids in their diet and Omega-3 fatty acids are essential for brain function and vision processing. Adding a daily Omega-3 fatty acid (EPA + DHA) supplement to the autistic child’s treatment plan is warranted. ” Elizabeth Strickland, MS, RD, LD

Omega-3 Fatty Acids Deficiency of Omega-3 fatty acids are linked to: l Autism l ADHD l Dyslexia l Dyspraxia l Depression l Anxiety

Omega-3 Fatty Acids Neurodevelopmental Disorders: Numerous studies indicate that Omega-3 fatty acids are deficient in ADHD, dyslexia, and dyspraxia. l These neurodevelopmental conditions have a degree of overlap with autism. l Abnormalities in fatty acid metabolism may account for many features common in these conditions. l Fatty Acid Metabolism in Neurodevelopmental Disorder: A New Perspective on Associations Between Attention-Deficit/Hyperactivity Disorder, Dyslexia, Dyspraxia and the Autistic Spectrum Prostaglandins Leukot Essent Fatty Acids 2000; 63: 1 -9 Richardson AJ, et al

Omega-3 Fatty Acids Autism Spectrum Disorder: l Studies to assess essential fatty acids for their role in autism report essential fatty acid deficiency in children with autism. “Reported DHA 23% reduced, total Omega-3 20% reduced, and Omega-6 unchanged in plasma. ” Plasma Fatty Acid levels in Autistic Children Prostaglandins Leukot Essent Fatty Acids 2001: 65: 1 -7 Vancassel S, et al

Omega-3 Fatty Acids “Supplementing children’s diets with Omega-3 fatty acids improves poor learning and behavioral problems. ” Journal of the Developmental and Behavioral Pediatrics April 2007 “Supplementing with Omega-3 fatty acids decreased hyperactivity in children with autism spectrum disorders. ” Biological Psychiatry 2007

Omega-3 Fatty Acids Many research studies indicate that supplementing with Omega-3 fatty acids reduces: l Hyperactivity l Inattention l Impulsivity l Anxiety l Cognitive problems

Omega-3 Fatty Acids Functions of Omega-3 Fatty Acids: l Brain development of the fetus, infant and young child l Maintenance of normal brain function throughout life l Vital for brain cell signaling l Prominent structural fatty acid in the gray matter of the brain & retinol tissue

Omega-3 Fatty Acids Omega 6 Omega 3 ↓ ↓ Linoleic Acid ↓ Gamma-Linoleic Acid (GLA) ↓ Arachidonic Acid (ARA) ↓ Prostaglandin (PG 1 & 2) Alpha Linolenic Acid (ALA) ↓ delta-6 desaturase Eicosapentaenoic Acid (EPA) ↓ Docosahexaenoic (DHA) ↓ Prostaglandin (PG 1)

Omega-3 Fatty Acids Adequate intake of Omega-3 Fatty Acids: Age EPA + DHA (combined) 1 – 3 years old 4 – 8 years old 9 – 13 years 70 mg/day 90 mg/day 120 mg/day Food and Nutrition Board Institute of Medicine, National Academies

Omega-3 Fatty Acids Adequate intake of Omega-3 Fatty Acids: Age EPA + DHA (combined) 1 – 3 years old 4 – 6 years old 7 years & older 390 mg/day 540 mg/day 650 mg/day National Institutes of Health (NIH)

Omega-3 Fatty Acids Source Salmon, Atlantic, farmed Herring, Pacific Herring, Atlantic Salmon, Atlantic, wild Tuna, fresh (blue fin) Mackerel, Atlantic Trout, mixed species Flounder Halibut EPA + DHA (mg/oz. ) 608 602 571 521 426 341 265 142 132 USDA Nutrient Data Laboratory

Omega-3 Fatty Acids FDA & EPA recommendations for women who are or may become pregnant and nursing mothers: l Do NOT eat shark, swordfish, king mackerel, and tilefish. l Limit canned albacore “white” tuna to 6 ounces per week. l Limit tuna steak to 6 ounces per week. l Limit other fish and shellfish to 12 ounces per week. l Check local advisories on safety of fish caught in your local waters. *If no advisory, limit to 6 ounces and do not eat any other fish that week.

Omega-3 Fatty Acids There are no recommendations for the amount of fish that is safe for children. FDA & EPA suggest to follow above recommendations, but serve smaller portions sizes.

Omega-3 Fatty Acids Supplements EPA + DHA Cod liver oil (liquid) Coromega™ (original) *Arctic cod liver oil *DHA Junior *Nordic Omega-3 Gummies *Nordic Naturals® products 1, 035 mg / teaspoon 580 mg / packet 207 mg / soft gel 52 mg / soft gel 68 mg / gummy Common Fortified Foods: Omega-3 enriched eggs Milk, Orange Juice, Yogurt, Smart Balance Spread

Additional Supplements Immune System “Many medical professionals in the autism community believe autistic children are prone to immune system dysfunction. ” Studies indicate that autistic children exhibit atypical immune function: l l l l l Abnormalities in T cells and T cell subsets Depressed responses to T cell mitogens Decreased natural killer cell function Lower percentage of helper-inducer cells Elevation of interleukin-12 Elevation of interferon-gamma Elevation of alpha-interferon levels Deficient form of the C 4 Bgene Antibodies to myelin basic protein & neuron-axon filament protein Children with Starving Brains a Medical Treatment Guide for Autism Spectrum Disorder Jaquelyn Mc. Candless, MD

Additional Supplements to enhance the immune system: l Vitamin A l Vitamin D l Vitamin E l Vitamin C l Zinc l Iron l Magnesium l Selenium l Dimethylglycine (DMG)

Additional Supplements to enhance cognitive function: l Iron l Zinc l Choline l Coenzyme Q 10 (Co. Q 10) l Carnitine l Ginkgo biloba

Additional Supplements Detoxification System It is a common belief in the autism community that autistic children have a dysfunctional detoxification system within their liver. l It is believed that autistic children can not effectively excrete toxins out of their body. l These toxins (mercury, lead, arsenic, pesticides, herbicides, and other chemicals) cross into the brain, cling to brain tissue, and damage the brain. l Autistic children may be more vulnerable to neurological damage caused by exposure to toxins. l

Additional Supplements to enhance the detoxification system: l Glutathione l Vitamin C l Selenium l Alpha-Lipoic Acid l N-acetylcysteine (NAC) l Trimethylglycine (TMG) l Milk thistle

Thank you!!!

The 10 – Step Nutrition Plan 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Transition to a healthy diet Consume adequate basic nutrients Select a multi vitamin/mineral supplement Select an omega-3 fatty acid supplement Treat child’s feeding problem Heal the gastrointestinal tract Identify and treat food allergies Consider special diets Trial response of high dose vitamin B 6 Consider additional supplements