This article, which discusses the interesting topic of diet and autism, was originally published in the February 2018 edition of NHD Magazine.
Autism is described as a lifelong developmental disability which can present in a range of ways, including: cognitive differences, sensory differences, communication differences, social differences and certain medical and mental health issues1-3.
Autism is also associated with unique strengths such as: good memory of facts, logical thinking skills and awareness of small details1,3.
Some of these differences can present challenges in terms of dietary intake, this can include: overeating, undereating, restrictive eating (or avoidant restrictive food intake disorder in severe cases), pica, difficulty with meal presentation or the eating environment, continuous grazing or ritualistic eating1.
This article discusses the practical management of dietary issues in the context of children with autism.
Dietitians can support a family to maximise the nutritional adequacy of their child’s diet; including advice on food substitutes and use of supplements as needed1.
Faltering growth is more commonly seen in younger children with autism; often because of gastrointestinal issues and/or restrictive eating2. Whereas, older children with autism seem more predisposed to becoming overweight; often due to a high intake of refined carbohydrates, sweet foods and savoury snacks, and a low intake of fruit, vegetables, wholegrains and fish2.
Although selective eating is an extremely common feature of autism, reassurance should be given if the child is growing well in order to reduce parental anxiety1.
Severe autism is associated with lower levels of calcium, iron, zinc, vitamin C, vitamin B3 and vitamin B64.
As with the general public it is also important to consider vitamin D status5. Correcting vitamin and mineral deficiencies in children with autism using appropriate supplements is advised as a first line treatment, which should be followed by other strategies to improve overall nutritional intake1.
However, achieving the recommended intake of micronutrients may be challenging as supplements may be refused, so a relaxed and pragmatic approach is usually best1. Unflavoured supplements, such as paediatric Seravit (SHS) can be better tolerated than flavoured versions; but this specific supplement needs to be combined with a fish oil supplement to provide essential or long chain fatty acids (examples include: Ideal Omega Swirl (Barlean’s), Lem-0-3 (Cytoplan), MorEPA and MorDHA (Nutritional Intelligence))2.
It is also important to monitor for signs of anaemia in those with a low iron intake; as advice on iron intake and/or iron supplementation may be indicated6.
Additional time is often needed in dietetic consultations, and it can be helpful to alter sensory aspects of the clinic setting to suit the individual where possible. For example, if a child with autism is hyper-auditory it is a good idea to limit the noise in the clinic room by closing windows, or if they are hyper-visual it may be helpful to reduce the amount of visual stimuli in the room (bright lights, colourful wall displays etc.). Equally, if a child is hypo-visual it may be useful to incorporate visual elements into the session.
In terms of mealtimes, some children with autism eat more when sitting with other people, whereas others prefer to eat by themselves4. Similarly, some children find it difficult to eat in a noisy atmosphere, but others eat better when there is music or a video playing in the background2,6.
Extra consideration may also be needed to account for sensory preferences for: specific cutlery or utensils, foods of specific colours or textures and overall food presentation1.
For example, children with autism often dislike mixed textures, such as milk and cereal together, so may prefer to have these presented separately1. If eating in a different environment (such as a restaurant) it can be helpful to prepare in advance by discussing where they will be going, who will be there, where they will be sitting and what they could speak to people about at the table6.
Similar to environmental adjustments it is important to adapt communication accordingly. Depending on the client this may include: the use of visual prompts, limiting the use of hand gestures, not overloading with instructions, using short closed questions, speaking more slowly, awareness of nonverbal communication, using consistent and specific language to discuss food, limiting ambiguous humour and sarcasm and incorporating the child’s interests and strengths into the session7.
Useful visual resources include: rewards charts, food planners, picture books, ‘Social Stories’ (developed by Carol Gray in 1991), the Picture Exchange Communication System (PECS), ‘Just Look & Cook’ visual cook books and ‘Dinner Winner’ trays6-7.
Reducing stress at mealtimes and creating a positive food environment is crucial1,4. Successful strategies vary a lot between individuals but sensible tips are outlined in the information box below2,6.
|Generally Helpful Mealtime Strategies:|
This gradual approach, also referred to as ‘food-chaining’, introduces new foods by linking from a current ‘safe food’ to a similar food (such as a different brand or shape of bread stick) and continuing in a stepwise manner as outlined in the charts below6.
This includes encouraging the child to touch, smell, lick and taste new foods and praising these actions even if the new food isn’t tolerated straight-away6.
It is also important to explain that this process can take a long time; in some cases significant progress can include: accepting being in the same room as a certain food, or accepting this on the plate without eating it. It is usually sensible to avoid ‘contaminating’ accepted foods with new foods by presenting them on separate plates and starting with a small amount of a new food then titrating upwards if tolerated.
Occupational therapy-led oral desensitisation programs can also be very useful1, these can include the use of brushes, massages, blowing bubbles, use of chewy tubes and ‘chewlery’.
A ‘food exchange’ is a similar approach where a food’s features are assessed and a food with similar qualities is exchanged for this (see table below – ‘Sensory Characteristics of Food Exchange system from p. 180 of the Manual of Dietetic Practice, 5th Edition)2.
|Acceptable food||Colour||Shape||Texture||Taste||Temperature||Exchange Foods|
|Rounded flat||Firm crispy||Salty||Hot||Pastrami|
|Cheese balls||Orange||Round||Crunchy||Salty||Ambient||Homemade salted popcorn|
As with any dietetic consultation it is important to use motivational interviewing techniques to support behaviour change, such as: rolling with resistance, accurate empathy and being led by the client and/or their family.
It is also key to set realistic goals in the context of autism, rather than trying to resolve all food related issues1.
With family members and some older children, it can be useful to explore psychological strategies such as cognitive behavioural therapy to de-catastrophize fears related to food.
Another relevant strategy is the ‘ABC of behaviour’ (as outlined below); this can help to identify whether the child is reacting to the food itself or to another environmental factor.
|A – Antecedent (i.e. triggers)||A baby cried or a new food was touching a ‘safe food’ etc.|
|B – Behaviour (i.e. what happened)||Child threw the dinner plate or ran away from the table etc.|
|C – Consequence||Parent threw food in the bin or there was an argument|
Keeping a food diary can also help to identify patterns of food refusal. A detailed food diary can include: the time, what was eaten, where was it eaten, volume consumed, response to the meal, who was present, other environment factors etc6.
It is crucial that all goals are clear and consistent between everybody involved in the child’s care, including the client, family members and carers. Autism outreach teams and The Autism Society can provide great support and resources for families. Working with speech and language therapy for those who have poor oral motor skills or extreme oral sensitivity can also be very important. And as mentioned above, occupational therapists can assess and clarify the child’s sensory profile and develop a suitable desensitisation programme1.
As each case is unique it is important to provide an individualised treatment plan based on a detailed dietary assessment.
For example, the BDA highlight that standard healthy eating guidelines are often inappropriate for those children with autism who have an extremely limited diet (i.e. those who eat less than 20 types of food)1. It is also important to explore the underlying issues for eating difficulties; such as sensory or social differences6. Some common nutritional issues, which may need to be considered on a case by cases basis, are listed in the table below1,6.
|Issue||Examples of Nutritional Advice|
|Constipation||Advice on gradually increasing fibre and fluid intake.|
|Tooth decay||Advice on reducing sugar intake, aiming to limit sweet foods to after meals and limiting overall snacking.|
|Overeating||Strategies to encourage movement, reduce portions, reduce snacking, and increase fruit, vegetable and fibre intake.|
|Undereating||Strategies to increase portions and high energy high protein advice.|
|Potential food hypersensitivity||Dietary assessment, use of food and symptom diary and advice on nutritionally balanced exclusion trials if indicated. If requested by the family, exclusion trials of gluten and casein should be supported by a dietitian to ensure nutritional adequacy; as long as the limited evidence base and pros and cons of this approach are discussed with the family in advance (based on an individual dietary assessment)1.|
To account for the numerous differences which can occur in autism, there are many aspects of dietary care to consider. This can include: monitoring growth and nutritional intake, correcting micronutrient deficiencies, making environmental and communication adaptations, encouraging positive and relaxed mealtimes, supporting with desensitisation to new foods and the use of psychological strategies.
Ensuring that treatment is individualised and working closely with other members of the multidisciplinary team, as well as family members, are also key aspects of supporting children with autism from a dietary point of view.
- BDA (2010) “Dietary Management of Autism Spectrum Disorder”
- Manual of Dietetic Practice (5th Edition)
- The National Autistic Society (NAS) website “Autism” [accessed December 2017 via: http://www.autism.org.uk/about/what-is/asd.aspx]
- BDA Food Fact Sheet “Autism”
- SACN (2015) “Draft Vitamin D and Health report”
- NAS website “Eating” [accessed December 2017 via: http://www.autism.org.uk/about/health/eating.aspx]
- NAS website “Communicating” [accessed December 2017 via: http://www.autism.org.uk/about/communication/communicating.aspx]
- Zoe Connor Dietitian (2011) “An Introduction to Autism – For Dietitians”
PDF of NHD Article The Dietary Management of Autism'
What is the dietary approach to autism? ›
The Gluten Free/Casein Free Diet is the removal of all wheat protein (gluten), and milk protein (casein) from the diet. Many parents and physicians have found that implementing the GF/CF diet relieves many of the symptoms associated with autism spectrum disorders.What are the dietary changes for autism treatment? ›
A healthy diet for people with autism means eating foods like grass-fed meat, pasture-raised eggs, organs, and fresh fruit. Make sure to avoid any processed foods with added sugar and vegetable/seed oils completely if you want to thrive. Avoid drinking anything with caffeine or added sugars or artificial sweeteners.What are the dietary preferences of individuals with autism? ›
Autistic children frequently prefer foods of a similar texture, typically either soft or hard /crunchy foods. For some, the eating issues emerge in infancy at the second stage of weaning (7-9 months) with the introduction of textured and lumpy foods.Why is diet important for autism? ›
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.What are feeding and eating challenges in autism? ›
Difficulties such as only eating a very few foods, not being able to eat at school, going long periods of time without eating or over eating and Pica (eating non-foods) can be difficult to understand and manage with parents and carers reporting feelings of anxiety, frustration and blame.What foods help high functioning autism? ›
- High quality proteins such as pastured chicken and eggs, grass-fed beef, and wild-caught salmon.
- A variety of fresh fruits or frozen fruits and vegetables.
- Whole grains like oats, brown rice, and quinoa.
- Foods rich in omega-3 fatty acids including nuts, seeds, and fish.
- Beans and legumes.
We have known since the 1970s that a nutritional approach can help autism, thanks to the pioneering research by Dr Bernard Rimland of the Institute for individual Behaviour Research in San Diego, California. He showed that vitamin B6, C and magnesium supplements significantly improved symptoms in autistic individuals.What is the best diet for autism and ADHD? ›
Dietary modifications have been linked to improvements in both ASD and ADHD symptoms. A randomized, controlled 12-month trial found that a gluten-free, casein-free, soy-free diet improved autism symptoms and non-verbal IQ in a significant percentage of autistic children and adults.What are the eating habits and dietary patterns in children with autism? ›
Some investigations have reviewed the consumption of children with ASD compared to those with typical development and determined some nutritional preferences of children with ASD. In general, they found stronger preferences for energy-dense foods like snacks, sweets, sugary beverages and juice in children with ASD.What are problematic feeding behaviors? ›
Behavioral feeding problems have more of an emotional than a physical basis, and include all the disruptive or problematic behaviors that can come up at mealtimes. They can include things like throwing food, crying or screaming to get out of eating, stealing food from others, or refusing to eat.
What is calming food for an autistic child? ›
Shellfish, Beans, Nuts, Seeds:
Incorporating zinc-rich foods such as shellfish, beans, chickpeas, peas, yogurt, cheese, cashews, and almonds is key to ensuring your child's nutrition. We highly encourage you to implement the foods mentioned above to your child's diet to improve behavioral signs.
- Use Sensory Objects. Sensory objects and toys are perfect for soothing the early stages of a meltdown. ...
- Provide an Escape. ...
- Offer Distractions. ...
- Try Breathing Techniques. ...
- Don't Underestimate Exercise and Movement. ...
- Start a Yoga Routine. ...
- Have a Game Plan Ahead of Time.
Some more recommended food items that help autism symptoms include: Prebiotic-rich foods (apples, asparagus, leeks, garlic, onions, bananas, and chicory root)Is yogurt good for autism? ›
Casein is the main protein in dairy products such as cow's milk, cheese, yogurt and ice cream. Some research has shown that this diet may improve some symptoms of autism like hyperactivity and communication, but it has not shown to improve digestive symptoms.Does dairy affect autism? ›
Children with autism (ASD) are much more likely to have a food intolerance to dairy than their peers. This mild allergy could explain why many parents have reported positive changes to their child's autism symptoms -including improved behavior - after eliminating dairy.
- Dairy Products (especially ice cream, yogurts, and cheeses). ...
- Sugar: Added sugar of any kind can be dangerous, it does nothing for our systems functionally. ...
- Caffeine: Children with ADHD, the addition of caffeine can be overwhelming.
Food preferences are the evaluative attitudes that people express toward foods. Food preferences include the qualitative evaluation of foods, and also how much people like and dislike them.What meals are sensory appealing? ›
- Beef or turkey jerky.
- Flavored or buttery crackers.
- Cheese crackers.
- Animal crackers.
- Apple slices.
- Chips – sweet potato or veggie straws.
- Carrot sticks or baby carrots.
- Thank the host/hostess for the invitation and give him/her the heads up about your allergies. ...
- Be specific in your explanation. ...
- Assess the situation. ...
- Be available for questions. ...
- Express your appreciation afterward.
- Available Time to Cook. Take a look at your week and determine how much time you have to cook. ...
- Seasonal Food Availability. ...
- Variety of Foods. ...
- Special Occasions. ...
- Financial Resources.
What are the reasons for special dietary requirements? ›
A special diet is one that cannot be selected freely from the main choices available. This could be due to an allergy, intolerance or other medical need; or because children are following a religious or cultural diet; or a vegetarian or vegan diet.
- Taste Preferences. Taste preferences often are cited as a primary motivator of individuals' food choices (Drewnowski, 1997; Drewnowski and Levine, 2003; Drewnowski et al., 1999). ...
- Personal and Social Factors. ...
- Employment Status. ...
- Acculturation. ...
- Access to Personal Transportation.