GLUTEN-FREE-CASEIN-FREE (GFCF) DIET IN CHILDREN WITH AUTISM Thanit Vinitchagoon, B.Sc., CDT. Certified Dietitian of Thailand Administrator of ‘Whatdidsheeat?’ on facebook
WHAT IS AUTISM? Autism is a neurodevelopmental disorder in the category of pervasive developmental disorders, and is characterised by
pervasive impairment in reciprocal socialisation qualitative impairment in communication repetitive or unusual behaviour. Autism is 1 of 3 disorders included in autism spectrum disorders (ASD) together with Asperger’s syndrome, and PDD-NOS.
(Levy SE, et al. Lancet. 2009; 374(9701): 1627-38.)
PREVALENCE OF AUTISM The prevalence of ASDs in developed countries is now considered to be at least 60 per 10,000. For autism disorder, estimated prevalence is between 10 and 20 per 10,000. ASDs occurs more commonly in boys, although the gender ratio depends on cognitive status and presence of minor dysmorphology.
(Levy SE, et al. Lancet. 2009; 374(9701): 1627-38.)
CURRENT TREATMENT OF AUTISM There is no known cure yet for autism. Emphasis is on early identification and intervention, aimed at maximizing the quality of life. Treatment usually consists of a comprehensive program of educational intervention developmental therapies behavioral treatment (Hurth J et al. Infants Young Children. 1999; 12: 17-26.) (Rogers SJ et al. J Clin Child Psychol. 1998; 27(2): 168-79.)
CURRENT TREATMENT OF AUTISM Many families are turning to alternative therapies discovered in the media, or anecdotal reports of parents although there is inadequate evidence to support the use. Some may actually produce hardships for families while creating false hope of miraculous cures.
(Hurth J et al. Infants Young Children. 1999; 12: 17-26.) (Rogers SJ et al. J Clin Child Psychol. 1998; 27(2): 168-79.)
GLUTEN-FREE CASEIN-FREE DIET (GFCF DIET) Start from hypothesis that some autistic symptoms may be the result of opioid peptides formed from the incomplete breakdown of foods containing gluten and casein. BBB
Increased intestinal permeability (Leaky gut syndrome) allows these peptide metabolites to cross the intestinal membrane, enter the bloodstream, and cross the blood-brain barrier (BBB), affecting the endogenous opiate system and neurotransmission within the central nervous system. (D’Eufemia P et al. Acta Padiatr. 1996; 85(9): 1076-9.) (Horvath K et al. J Pediatr. 1999; 135(5): 559-63.)
GLUTEN-FREE CASEIN-FREE DIET (GFCF DIET) This may explain why many children have associated GI symptoms, and because many of these children cannot adequately express their pain or GI comfort verbally, they may react with extreme behaviors.
(D’Eufemia P et al. Acta Padiatr. 1996; 85(9): 1076-9.) (Horvath K et al. J Pediatr. 1999; 135(5): 559-63.)
GI SYMPTOMS IN AUTISM A research found that there may be irregularities in the absorptive properties of the mucosa of the intestinal wall in children with autism. More than 85% of the autistic children suffered with at least 1 GI symptoms, compared with only 12% of their control siblings.
But GI symptoms may be present in an only certain subgroup of individuals with autism, since there is also a research that found no associations among GI inflammation, celiac disease, food intolerance, recurrent GI symptoms, and the development of autism. (Wakefield AJ et al. Gut. 1998; 42: A84-5.) (Horvath K et al. Curr Gastroenterol Rep. 2002; 4(3): 251-8.) (Black C et al. BMJ. 2002; 325: 419-21.)
CLINICAL EVIDENCES OF GFCF DIET IN AUTISM
Knivsberg AM, Reichelt KL, Hoien T, Nodland M. A Randomised, Controlled Study of Dietary Intervention in Autistic Syndromes. Nutritional Neurosciences. 2002; 5(4): 251-61.
Code
Age (months)
Number of autistic traits
Non verbal cognitive level
Linguistic age in months
Motor problems
Before
After
Before
After
Before
After
Before
After
A
62
15
5
111
123
27
33
37
22
B
67
10
8
-
-
-
-
40
40
C
71
16
9
56
56
24
30
37.5
29
D
78
10
2
100
98
57
75
11.5
5
E
82
10
6
53
62
36
54
37
32.5
F
102
12
5
41
44
39
51
36.5
34
G
107
12
3
116
118
99
120
2
10
H
109
12
5
133
151
88
108
22
23
I
116
13
4
35
43
27
30
38
38
J
120
15
9
84
85
102
98
31
29
Number of children in the diet and the control group observed to have attention problems before and after the experimental period of 1 year . * P <.05 Wilcoxon two-tailed paired test
Diet group
Control group
15
15
10
10
Before
5
After
0
Before
5
After
0 1*
2
3*
4*
1 at times could be aloof 2 was easily distracted 3 needed routine and rituals 4 how the child responded to teaching
1
2
3
4
Number of children in the diet and the control group observed to have cognitive problems before and after the experimental period of 1 year. * P <.05 Wilcoxon two-tailed paired test
Diet group
Control group
10
10 Before
5
Before
5
After 0
After 0
1
2*
3
4*
1 had problems with causal relations 2 could judge dangerous situations 3 would express imagination 4 had a restricted number of interests
1
2
3
4
The development during the experimental period of 1 year within the groups and between the groups with regard to autistic behavior, non verbal cognitive level, linguistic age, and motor problems * Non parametric two-tailed Wilcoxon test ** Non parametric two-tailed Mann-Whitney U test Diet group
Control group
Significance of Significance difference of between difference* groups**
Mean after
Significance of difference*
Mean before
Mean after
12.5 (SD 2.2)
5.6 (SD 2.4)
0.005
11.5 (SD 3.9)
11.2 (SD 5.0)
0.798
0.001
Non verbal cognitive level (n=9)
81.0 (SD 35.9)
86.7 (SD 38.5)
0.03
84.6 (SD 36.6)
74.3 (SD 31.4)
0.5
0.004
Linguistic age (n=9)
55.4 (SD 32.3)
66.6 (SD 35.1)
0.015
47.8 (SD 23.9)
55.7 (SD 28.3)
0.035
0.375
Motor problems (n=10)
29.3 (SD 13.1)
26.3 (SD 11.5)
0.161
24.7 (SD 14.6)
27.8 (SD 12.2)
0.123
0.040
Mean before
Autistic traits (n=10)
Mari-Bauset S, Zazpe I, Mari-Sanchis A, Llopis-Gonzalez A, MoralesSuarez-Varela M. Evidence of the Gluten-Free and Casein-Free Diet in Autism Spectrum Disorders: A Systematic Review. Journal of Children Neurology. [Epub ahead of print] 30 April 2014
PRACTICAL APPROACHES FOR GFCF DIET
CONSIDERATIONS OF USING GFCF DIET • Many children with ASD have seriously restricted food repertoires that make it difficult to eliminate foods containing gluten and/or casein.
• There are reports of bone loss in children who have been on the GFCF diet. • Nutritional status need to be monitored, and in some cases vitamin and mineral supplements may be indicated. (Fe Zn Vitamin B Folate – Gluten free, Ca Vitamin D Vitamin B2 Protein – Casein free) • Parents should also be encouraged to keep daily dietary records to share with registered dietitian or healthcare provider. • Closely communication with school personnel and caretakers need to be done closely to ensure the maintenance of dietary restriction. This may make a child looks “special” and “different” (Elder JH. Nutr Clin Pract. 2008; 23(6): 583-8.)
NUTRITIONAL STRATEGIES FOR IMPLEMENTING GFCF DIET • Eliminating all milk products removes a critical source of calcium and vitamin D. In addition, additional sources of protein may be required because dairy products are often a major source of protein in a child’s diet. These needed minerals are not always included in the “gummy” type vitamins. • Removing grains like wheat, barley, rye, and oats from your child’s diet eliminates important nutrients such as the B vitamins, iron, and fiber. Children who do the GFCF diet may benefit from vitamin and mineral supplements. • Gluten isn’t always easy to detect. While some sources like bread, pasta, and cereal may be obvious, others such as deli meats, salad dressings, and broths may be less so.. Read labels carefully.
DIFFICULTIES EXPERIENCED IN IMPLEMENTING GFCF DIET • Social isolation, unable to eat out, or share food-related activities outside home • Finding acceptable gluten and casein free alternatives, alternative treats. Lack of variety. • Increased food preparation and cooking time for mom • Child viewing diet as punishment and not understanding why he could not eat same food as others • Cost of the diet • Coping with behavior on initiating diet (Cornish E. J Hum Nutr Dietet. 2002; 15: 261-9.)
WEIGHING PROS AND CONS Does the family have the resources to purchase foods in the GFCF diet that are often more expensive, and are these foods readily available? Has the family considered the extra time and effort that may be needed to prepare the diet? Is there a commitment by at least 1 family member to keep accurate daily records of food intake and behavioral changes? Are there adequate plans regarding how to ensure dietary compliance at home and, when applicable, at school?
(Elder JH. Nutr Clin Pract. 2008; 23(6): 583-8.)
WEIGHING PROS AND CONS Is there another parent or professional who has implemented the diet and who can offer practical advice for preparing and implementing the GFCF diet? Are there clinicians and/or researchers in the family’s geographical area who might assist in systematically evaluating the GFCF diet? What is the overall health status of the child? Is there a plan for regular monitoring, including weights? Does the child have a limited food repertoire that, if further limited by the GFCF diet, might result in a dangerously compromised nutritional status? (Elder JH. Nutr Clin Pract. 2008; 23(6): 583-8.)
FOOD SOURCES OF GLUTEN-CASEIN Foods containing gluten
Foods containing casein
• Wheat, rye, barley, malt, oats
• Milk
• Bakeries and pastries made with wheat flour
• Powdered milk, yoghurt
• Dextrin and maltodextrin
• Potato chips/ fries
• Cheese and butter • Cream cheese
• Ready-to-eat sauces/ gravies
• Ice-cream
• Bologna and hot-dogs
• Processed foods containing milk
• Non-dairy creamer
WHAT COULD THE CHILD EAT? • Starches : potatoes, rice, gluten-free pasta and cereals • Fruits and vegetables • Meats : chicken, fish, meats, legumes • Fats and oil : vegetable oils, nuts • Seasonings : salt, herbs, sugar • Milk alternatives : soymilk, rice milk, almond milk
ALTERNATIVE SOURCES FOR NUTRIENTS AT RISK Nutrient Needs
Alternative Sources
Vitamin D
Fortified rice, soy, and almond milk; cod liver oil; tofu, eggs; short-term exposure to sunlight; supplements
Calcium
Fortified rice, soy, and almond milk; fortified orange juice; beans, broccoli, spinach, kale, tofu, tempeh; supplements
Iron
Red meats, pork, chicken (mainly in dark meat), shellfish, egg yolks, spinach, soybean nuts, prunes, raisins; supplements
Protein
Eggs, nuts and seeds, lean meats, beans, peanut butter
GFCF DIET RECIPES
CHEWABLE DIETARY SUPPLEMENTS
CONCLUSION
Since there is currently no curative interventions for children with autism yet, alternative approaches have become popular with hope, including GFCF diet.
However, the lack of solid evidence for the “pros” of GFCF diet along with several considerations regarding “cons” prevent the recommendation of using GFCF diet as a standard treatment for children with autism be implemented. Rationale for the use should be based on individualized decision. Since current evidence does not support the use, if the GFCF is to be implemented, it should be done safely and nutritionally adequate using carefully nutrition and dietetic plans involving healthcare providers especially registered dietitians cooperating with family and caretakers..
THANK YOU FOR YOUR ATTENTION :)