Food Selectivity in Children with Autism

Transcription

1 Food Selectivity in Children with Autism Linda Bandini PhD, RD Department of Health Sciences Boston University And Eunice Kennedy Shriver Center University of Massachusetts Medical School Developmental Disabilities Developmental disabilities are a diverse group of severe chronic conditions that are due to mental and/or physical impairments. Developmental disabilities begin anytime during development up to 22 years of age and usually last throughout a person s lifetime. Autism Spectrum Disorder Identified Prevalence of ASD ADDM Network Combining Data from All Sites ASD is a developmental disability that causes substantial impairments in: Surveillance Year Birth Year Number of Sites Reporting This is about 1 in X children 1 in 150 Social communication/interaction Restricted and repetitive behavior in in in in in 68 Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Nutritional Concerns in Children with ASD What do we know about food selectivity in children with ASD? Food Selectivity What parents tell us Nutrient Adequacy of Diets Weight Status What is reported in the scientific literature 1

2 What Parents Tell Us What Does the Scientific Literature Tell Us? Picky eaters eating only a few foods, or having aversions to specific foods. Child will eat a specific food frequently throughout the day. Children refuse food based on texture, color, smell and temperature of the food; will only eat a specific brand of food. Few studies, many have small numbers of children and the methodology is variable. Most indicate that children with autism eat less variety of foods than typically developing children An Assessment of Food Acceptance in Children with Autism or PDD-NOS Objective: to classify feeding problems in children with ASD through observational assessment N=30 children with ASD 22 male, 8 female Ages 3-14 years Feeding behaviors assessed in 6 sessions using the Munk & Repp procedures. Ahearn, et al, 2001 Study Design Direct observational assessment of feeding 6 feeding sessions Three items from each food category (fruit, vegetable, starch & protein) were presented One item each session was pureed Children were instructed to try a bite Each food was given a score of acceptance, expulsion, disruption, complete food refusal based on the child s response to the food Level of acceptance analyzed as low, moderate & high Ahearn WH, et al., 2001 Results Conclusions & Limitations Levels of observed acceptance: 4 children accepted >60 bites (high) 9 children accepted bites (moderate) 17 children accepted <30 bites (low) p<.025 when compared with chance findings 17 children exhibited selective feeding behavior Over 50% of participants exhibited low levels of food acceptance Limitations: The assessment may have presented foods in a manner that was foreign to the children No control group for comparison Small study population Ahearn WH, et al., 2001 Ahearn, et al, 2001 Ahearn WH, et al., 2001 Ahearn, et al,

3 Number of foods eaten by food group Food Selectivity in Children with and without Autism Schreck et al., 2004 Participants: Autism (n=138) Control (n=298) Food selectivity Methods: Children s Eating Behavior Inventory Food Preference Inventory (list of foods from each of the 5 food groups) 0 Fruits Dairy Vegetables Proteins Starches ASD group TD n=138 n=298 Children with ASD eat significantly fewer foods than typically developing (TD) children No significant differences found in familial eating patterns Schreck et al. (2004) cont d Limitations Children with autism were more likely to: exhibit food refusal eat a narrower variety of food require specific utensils require specific food presentations accept food of low texture Lack of operational definition of food selectivity Food characterization unclear Parental report Avon longitudinal study of parents and children (ALSPAC) Examined dietary patterns in a cohort of children including children with a diagnosis of ASD by age 11. Questionnaires on child feeding and diet completed at 6, 15, 24, 38 and 54 months. Weight and height obtained ALSPAC -Results No differences in infant feeding score between children with and without ASD at 6 months Toddlers and pre-school aged children with ASD exhibited more feeding concerns. Children with ASD consumed less vegetables, salads and fresh fruit than controls. The diet of children with ASD had less variety than controls at 3 years Children with ASD had lower intakes of Vitamin C, Vitamin D, and higher intakes of iodine than controls. No differences in mean height, weight or BMI. Emond et al, 2010 Emond et al,

4 ALSPAC-conclusions Children with ASD had diets with less variety, fewer vegetables and fresh fruits than controls. Strengths: Population based study Feeding data obtained before diagnosis Limitations: - Diagnosis from clinical records - Variety score based on category never Primary AIM: To determine if children with autism have a higher degree of food selectivity than typically developing children First step: Children s Activity and Meal Patterns Study (CHAMPS) To operationalize the definition of food selectivity NIH - #HD CHAMPS Study Measures of Food Selectivity in CHAMPS 53 participants with ASD and 58 typically developing children Ages 3-11 years Criteria for ASD established with ADI-R Dietary Assessment - Diet History Interview - Food Frequency Questionnaire - 3 day Food Record Variable Food refusal Limited repertoire of foods High Frequency of Single Food Intake (HFSFI) Method FFQ 3-day food record FFQ Food frequency questionnaire (FFQ) Participant Characteristics CHAMPS Autism Typical N Age (yr) 6.6(2.1)* 6.7(2.4) DAS 85.7 (21.9) NA Vineland Score 71.1 (12.4) NA Sex, male (%) 83% 78% Race, white (%) 83% 76% *mean (SD) Bandini, et al., Journal of Pediatrics, 2010 Autism Typical N Mean of foods refused (SD) Total foods 45 (26) 21 (19) Vegetables 11 (6) 6 (5) Percentage of foods refused (SD)* Total foods 42%(21) 19 %(16) Vegetables 63% (31) 33% (27) p< *Foods refused as a percent of those offered Bandini, et al., J of Pediatrics,

5 Food repertoire: number of different foods eaten over a 3 day period Autism Typical N Mean number 19±6 23±5 of foods * CHAMPS CHAMPS # of children with high frequency of single food intake Autism Typical N Single food eaten: 6 times per day 2 (4%) 0 * Adjusted for age, sex, race p< or 5 times per day 3 (6%) 1 (2%) Bandini, et al., J of Pediatrics, 2010 Bandini, et al., Journal of Pediatrics, 2010 Autism symptomology and food selectivity Sensory symptoms observed in children with ASD Sensory sensitivity Need for sameness Sensory over-responsiveness Sensor under-responsiveness Sensory seeking Sensory Sensitivity Sensory issues are extremely common in children with ASDs Sensory issues are seen in very young children and seem to persist Sensory issues are seen across a range of severity of ASD Potential correlates of food selectivity Sensory characteristics of food Texture Temperature Color Presentation of food Mixing of foods together Foods touching other foods Brand of the food Shape 5

6 Percent (%) Percent (%) Food Refusal Based on Sensory Characteristics of Food Variety of fruit and vegetable intake *** Autism Typical N Fruits 6.3 (3.3) 9.4 (3.0) Vegetables 5.8 (4.8) 10.8 (4.8) Oral Sensory 15.7 (5.5) 22.9 (2.9) Sensitivity score ***p<0.001 ASD TD n=53 n=58 Hubbard 2014, et al FFQ : 13 fruits and 20 vegetables listed Potential correlates of food selectivity Food Refusal Based on Presentation of Food Sensory characteristics of food Texture Temperature Color Presentation of food Mixing of foods together Foods touching other foods Brand of the food Shape *p< *** * **p<0.01 N=53 n=58 * ** * * ASD TD n=53 n=58 Hubbard et al, 2014 Feeding problems in children with ASD Potential factors associated with food selectivity Nutrient adequacy Family mealtimes Parent stress Eating out There is a greater level of feeding concern in children with ASD Sharp et al. (2013) 6

7 Number of Foods Eaten (3-day Diary) Relationship between food selectivity and nutrient adequacy Results on specific nutrients vary among studies Small samples sizes Difference in definition of food selectivity Few used cut point method Is Food Selectivity Related to Nutrient Inadequacy? Examined 8 nutrients and compared them to EAR/AI for age and gender*: Vitamins A, C, D, E Calcium Fiber Zinc Iron * NDSR for nutrient analysis Limited Repertoire and Nutrient Inadequacy Conclusions Children with ASD refuse more food and have a more limited food repertoire than typically developing children after adjusting for age and sex. Texture and presentation of food (foods mixed together and foods touching each other) are frequently reported as reasons for food refusal in both groups, but more so in children with ASD. Number of nutrients in which AI/EAR was not met Overall, studies provide variable results on nutrient adequacy and food selectivity in children with ASD. Practice implications Strategies to increase food acceptance Screen for feeding problems Assess dietary adequacy Monitor growth and weight status Nutrition Sensory Behavior Interdisciplinary Approach (Registered Dietitian) (Occupational Therapist/ Speech Pathologist) (Behavioral Psychologist) 7

8 Treatment Strategies Future directions Sensory strategies Behavioral interventions To determine if food selectivity persists in children with ASD To understand how food selectivity influences social interactions and opportunities To further understand the factors associated with food selectivity To understand long term effects of food selectivity on overall health To inform the development of interventions to help decrease food selectivity Healthy Weight Research Network for children with ASD and developmental disabilities Funded by HRSA Maternal and Child Health Bureau: UA3MC25735 Activities: Establish a research agenda for this emerging field Support pilot research activities Conduct secondary data analysis Leverage additional extramural funding Website HWRN.org 8