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. Author manuscript; available in PMC: 2021 May 10.
Published in final edited form as: J Autism Dev Disord. 2012 Apr;42(4):549–556. doi: 10.1007/s10803-011-1268-z

Food Variety as a Predictor of Nutritional Status Among Children with Autism

Michelle H Zimmer 1, Laura C Hart 2, Patricia Manning-Courtney 3, Donna S Murray 3, Nicole M Bing 3, Suzanne Summer 3
PMCID: PMC8108121  NIHMSID: NIHMS1698484  PMID: 21556968

Abstract

The frequency of selective eating and nutritional deficiency was studied among 22 children with autism and an age matched typically developing control group. Children with autism ate fewer foods on average than typically developing children. (33.5 vs. 54.5 foods, P < .001) As compared to typical controls, children with autism had a higher average intake of magnesium, and lower average intake of protein, calcium, vitamin B12, and vitamin D. Selective eaters were significantly more likely than typical controls to be at risk for at least one serious nutrient deficiency (P < .001).

Keywords: Autism, Nutrition, Feeding disorder, Food Selectivity

Introduction

Autism is a neurodevelopmental disability characterized by lack of social and emotional reciprocity, limited verbal and non verbal language skills and the presence of stereotyped and repetitive behaviors. The prevalence of autism has been increasing the last several decades and autism is now thought to be a relatively common neurodevelopmental disorder with estimates of 1 case per 110 individuals. (Centers for Disease Control and Prevention (CDC) 2009).

Feeding problems including food refusal, limited dietary intake, and behavior problems at mealtime are common clinical concerns reported by parents of children with autistic disorder. Studies of feeding behavior among children with autism corroborate parental reports, indicating high rates of selective eating, problematic mealtime behavior, and food idiosyncrasies (Ahearn et al. 2001; Bandini et al. 2010; Johnson et al. 2008; Lindsay et al. 2006; Schreck and Williams 2006; Williams et al. 2005).

Research papers examining nutrition among children with Autism Spectrum Disorders (ASD) have reported conflicting results about the extent of the nutritional deficiencies in this population. Some papers have reported that macronutrient intake of children with autism did not appear to differ from children with typical development (Emond et al. 2010; Johnson et al. 2008; Levy et al. 2007). Others have reported that children with autism were not meeting Dietary Reference Intakes (DRIs) of various nutrients including folic acid (Herndon et al. 2009; Wei et al. 2010), niacin (Cornish 1998; Herndon et al. 2009), vitamin A (Bandini et al. 2010; Herndon et al. 2009 Wei et al. 2010), vitamin B6 (Cornish 1998; Wei et al. 2010), vitamin C (Cornish 1998; Herndon et al. 2009; Wei et al. 2010), vitamin D (Bandini et al. 2010; Cornish 1998; Lindsay et al. 2006), vitamin K (Johnson et al. 2008; Lindsay et al. 2006), iron (Cornish 1998; Herndon et al. 2009; Ho et al. 1997; Johnson et al. 2008; Wei et al. 2010), zinc (Cornish 1998; Wei et al. 2010), and calcium (Bandini et al. 2010; Cornish 1998; Herndon et al. 2009; Ho et al. 1997; Johnson et al. 2008; Lindsay et al. 2006; Shearer et al. 1982; Wei et al. 2010)

Studies comparing nutrient intake of children with autism to typical controls have often minimized any difference in nutrient intake seen between groups and have suggested that as a group, children with autism did not differ significantly from controls in terms of nutrient intake. Shearer et al. (1982) reported lower calcium and riboflavin than typical controls but concluded that they failed to find major group differences in reported intake on three day diet records of children with autism versus controls. A few years later, Raiten and Massaro (1986) published an analysis of seven day diet records of 40 children with autism compared to 36 typical children, and found more perceived feeding problems, but higher intake of most nutrients (protein, carbohydrates niacin, thiamin, riboflavin, calcium, phosphorus, and iron) among the autism group, again concluding that restricted eating habits did not appear to be adversely affecting nutrient intake. More recently, Herndon et al. (2009) reported on three day dietary intake of 46 well characterized children with autism and 31 typical controls finding that children with autism had higher intake of vitamin B6 and vitamin E, but significantly lower iron, calcium, vitamin D intake than controls. The authors concluded that large proportions of children in both groups did not meet dietary intake recommendations for many nutrients.

It is important to note that in most previous studies, selective eating among children with autism has not been examined as a potentially significant variable influencing nutrient intake. A few studies, however, suggest that this may be an important variable to consider. Cornish (1998) reported that children with autism who are selective eaters choose a few foods to eat, which place them at nutritional risk, but the nutrient deficiencies vary widely depending on the foods that the child chose to eliminate from their diet. Overall, 53% were deficient in at least one nutrient, but these deficiencies varied widely among the group ranging from inadequate vitamin C, iron, vitamin D, niacin, riboflavin, vitamin B6, calcium, or zinc intake. Another study by Lindsay et al. (2006) assessed the nutritional status for 20 children with autism who were participants in a randomized placebo-controlled trial of risperidone for significant disruptive behaviors. Data reflected that although as a group these children met dietary intake standards, there was much individual variability in dietary intake among the group. For example, calcium intake was low for more than 50% of the sample. Yet, four participants consumed higher levels of calcium than the dietary reference guidelines recommended.

Surprisingly, it is not known whether selective eating is associated with increased risk for nutritional deficiency among children with autism. Most studies that have looked at nutritional status among children with autism have not separated out selective eaters from the overall group of children with autism, making assessments of risk related to selective eating difficult. Therefore, the specific aims of this study are to investigate whether children with autism are more likely to be selective eaters, and whether selective eating among children with autism places them at increased risk for nutritional deficiency. We hypothesized that, as seen in previous studies, children with autism would be more selective eaters than a typically developing control group. We also hypothesized that children with autism who are selective eaters would be more likely to have nutrient deficiencies than autistic children who were not selective and a typically developing comparison group.

Methods

Participants

This observational study was part of a larger case control study of nutritional factors affecting fatty acid levels in autism. Nutrition status and intake data were available for 22 children with Autistic Disorder, diagnosed by Autism Diagnostic Observation Schedule (ADOS) (Lord et al. 1999) and Autism Diagnostic Interview (ADI-R) (Lord et al. 1994), and for a comparison group of 22 unrelated age matched (±1 year) typically developing children. Exclusion criteria included the diagnosis of a genetic syndrome known to be associated with symptoms of autism (i.e. Fragile X syndrome), a diagnosis of PDD-NOS or Asperger syndrome, use of dietary supplements or dietary restrictions including the gluten-free, casein-free (GFCF) diet. The Institutional Review Board at Cincinnati Children’s Hospital Medical Center approved the protocol, and a parent or guardian provided written informed consent before enrollment.

Data Collection

Dietary intake and nutritional status was measured by food frequency questionnaire and body mass index, respectively.

Dietary Intake

The Harvard Semi Quantitative Food Frequency Questionnaire (FFQ) is a 174 item parent report questionnaire which has been validated in typically developing adult (Willett et al. 1985, 1987, Willett 2000; Salvini et al. 1989; Feskanich et al. 1993; Rimm et al. 1992; Hernandez-Avila et al. 1998) and pediatric (Eck et al. 1991; Treiber et al. 1990) populations and is commonly used as a measure of average food intake over time. It has been validated against 24 h food records and diet recalls and is felt to be at least equivalent for assessing nutrient intake as compared to these methods (Patterson et al. 1999). The FFQ asks the participant’s parent or primary caretaker to indicate how many times a month, week, or day (8 frequency options) the participant ate a given food. Questionnaires were sent to Harvard Nutrition Department for analysis and a report on nutrient intake for each study participant was generated. Average daily intake without vitamins and supplements for the following macronutrients (calories, fat, carbohydrates, protein) and micronutrients (iron, calcium, magnesium, zinc, vitamin A, niacin, folate, vitamin B6, vitamin B12, vitamin D) was used in the analysis.

Body Mass Index (BMI)

BMI was calculated from height and weight measurements and converted to z scores then a percentile was recorded using standard formula and charts. At risk for underweight was defined as below 15th percentile for age and gender. Underweight was defined as a BMI less than 5th percentile for age and gender.

Outcomes of Interest

Food Variety (FV) Score

To assess selective eating, a food variety score was calculated for each subject from the raw data summarized in the FFQ. For each of the 174 FFQ items, parents reported how often the food was eaten on average, over the last 12 months. Responses were recorded on a multiple choice ranked scale ranging from never, less than once a month, 1–3 times per month, several times a week, once a day or several times a day. Foods eaten at least once a month were tallied to obtain a food variety score.

Selective Eaters

A typically developing comparison group (n = 22) who participated in the larger study also completed food frequency questionnaires. This group was used to estimate average food variety of typically developing children. Low food variety was defined as having a food variety score 1 standard deviation or more below the mean of the typically developing group. The range of scores was examined, and a natural breakpoint in food variety score for the group of children with autism also occurred at this value 1 SD below the typical mean, further validating the use of 1 SD below the mean as a natural cut off score.

Estimate of Nutrient Adequacy/Deficiency

To assess risk of inadequate of nutrient intake, the Estimated Average Requirement (EAR) cut point method (Barr et al. 2002) was used. Briefly, each subject’s usual intake of each nutrient was calculated. For each nutrient, the subject was categorized as to being at risk for inadequate intake, or not, based on whether they were meeting the Estimated Average Requirement (EAR) for that nutrient. The EAR, from the US National Academy of Sciences’ Food and Nutrition Board, measures of level of intake that provides adequate nutrition only 50% of the population and has been used in other studies as a way to measure group risk of dietary inadequacy. For each macronutrient, a similar cut point method was used, but the low end of the Acceptable Macronutrient Distribution Range (AMDR) was used as the cut off point to assess risk of inadequate intake. (Institute of Medicine 2001)

Statistical Analysis

Data were entered into an Excel spreadsheet, were double entered to ensure accuracy, then uploaded into Stata 10 for statistical analysis. Box plots and histograms were used to explore the nutrition variables. Food variety scores and many nutrient intake variables were found to be skewed, therefore nonparametric Wilcoxon Rank Sum Test was used to compare food variety scores of children with autism to their matched controls. The autism sample was analyzed as a whole compared to controls and was also divided into two subgroups: selective eaters (n = 12) and non selective eaters (n = 10) based on an a priori decision to set low food variety at one standard deviation below the mean food variety score of typically developing control group. For each nutrient, the mean (SD) and range were reported and means were compared among the three groups using the previously mentioned Wilcoxon rank sum test. Significance level for all statistical comparisons was set at P < .05 with two tailed alpha. For each nutrient, contingency tables were generated to determine the number and proportion of subjects in each group (autism selective eaters, autism non selective eaters and typical controls) who were at risk for inadequate nutrient intake not meeting the EAR or not reaching the lower end of the AMDR. Chi square analyses and Fischer exact tests were used to determine whether the proportion of children meeting or not meeting DRI recommendations were different between groups. Statistical significance was set at two tailed alpha P < .05.

Results

The demographic characteristics of the study subjects are outlined in Table 1. As expected there was a predominance of males in the autism group (91%) as compared to controls (45%). This difference was statistically significant (P < .001). Race did not differ significantly between groups. As a group, the ADOS and ADI scores were well above the cutoff for an autism spectrum disorder. Although Body Mass Index (BMI) data were missing for four of the control subjects, these groups appeared to have similar BMI percentiles overall (60th vs 62nd percentile, P = .4)

Table 1.

Demographic characteristics

Autism
(n = 22)		 Typical development
(n = 22)
Age, years (SD) 8.2 (±3.2) 8.1 (±3.3)
Gender (%male) 91 45
Race
 % Causacian 95 77
 % Black 5 23
ADOS, Mean (SD) 16 (3.3)
ADI-R, Mean (SD) 21.3 (6.1)
Vineland composite SS mean (SD) 109.6 (9.4)
BMI percentile (SD) 60 (32) 62 (n = 18) (34)
BMI range 2 – 99 1 – 99
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Food Variety

Figure 1 illustrates the mean Food Variety Score of children with autism compared to age matched children with typical development. Food Variety was defined as the number of foods being eaten at least one per month. Children with autism tried a mean of 33.5 (SD ±12.6) foods per month while an age matched group of children with typical development tried a mean of 54.5 (SD ±18.9) foods per month. This difference was statistically significant. (P < .001)

Fig. 1.

Fig. 1

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Food variety scores of subjects with autism and typical development. *P < .05 Wilcoxon rank sum test

Comparison of Average Nutrient Intake

The average nutrient intake of the typically developing children was compared to the group of children with autism. Table 2 summarizes the results of the nutrient analysis. As compared to typical controls, children with autism had a higher average intake of magnesium (314.89 vs. 265.93 mg/d, P = .02), and lower average intake of protein (72.77 vs. 92.64 g/d, P = .01), calcium (945.18 vs. 1,221.98 mg/d, P = .01), vitamin B12 (4.69 vs. 6.66 mcg/d, P = .01) and vitamin D (198.62 vs. 319.86 IU/d, P = .005). The group with autism was then categorized into selective (n = 12) and not selective eaters (n = 10). The analysis revealed that the nutrient intake of non selective eaters with autism was not significantly different than the intake of typical control group. However, the nutrient intake of selective eaters with autism differed from both the autism-non selective eater group and the typically developing controls. Specifically, selective eaters with autism had significantly lower average daily intake of calcium (742.05 vs. 1,188.93 mg/d, P < .001), vitamin B12 (3.48 vs. 6.14 mcg/d, P = .02) and vitamin D (129.53 vs. 319.86 IU/d, P < .001) than non selective eaters with autism. Selective eaters had significantly lower average intake of protein (60.14 vs. 92.64 g/d, P = .01), calcium (742.05 vs. 1,221.98 mg/d, P < .001), vitamin A (4236.85 vs. 6,411.88 IU/d, P = .02), vitamin B12 (3.48 vs. 6.66 mcg/d, P = .01) and vitamin D (129.53 vs. 319.86 IU/d, P < .001) than typical controls.

Table 2.

Comparison of average nutrient intake of children with autism and controls

Daily nutrient intake DRI (4–8 yrs/9–13yrs) Autism mean(SD) range Typical devel. mean (SD) range All (n = 22)
All (n = 22) Selective Eaters (n = 10) Not selective eater (n = 12)
Macronutrients
Energy (kcal/d) 1400–1600/1600–2200 2147.15 (873.83) 1871.36 (744.21) 2478.11 (938.96) 2005.50 (543.62)
709.96–3857.93 709.96–3174.86 1335.93–3857.93 1244.19–3376.38
Total fat (g/d) 39–62/62–85 74.38 (34.11) 63.24 (26.63) 87.75 (38.52) 72.01 (26.12)
18.23–143.32 18.23–104.24 38.2–143.32 45.53–161.38
Carbohydrates (g/d) 130/130 306.16 (134.40) 275.55 (136.02) 342.90 (129.56) 253.65 (66.44)
124.91–538.76 124.91–525.21 180.42–538.76 134.31–381.65
Protein (g/d) 19/34 72.77 (32.50)a 60.14 (26.33)a 87.94 (40.31) 92.64 (23.71)
15.55–163.89 15.55–109.54 38.43–163.89 66.79–160.27
Minerals
Iron (mg/d) 10/8 16.41 (7.76) 18.30 (9.67) 14.14 (3.94) 13.96 (5.53)
3.77–33.42 3.77–33.42 8.73–19.6 5.47–26.04
Calcium(mg/d) 800/1300 945.18 (547.77)a 742.05 (496.00)a,b 1188.93 (527.64) 1221.98 (323.36)
221.61–2218.84 221.61–2066.79 643.85–2218.84 587.75–1792.48
Magnesium (mg/d) 130/240 314.89 (88.98)a 289.83 (82.88) 344.97 (90.74) 265.93 (83.08)
121.03–482.2 121.03–400.71 195.09–482.2 169.23–547.41
Zinc (mg/d) 5/8 12.38 (4.93) 11.52 (5.60) 13.42 (4.03) 13.80 (3.45)
3.98–24.33 3.98–24.33 7.32–21 7.71–19.74
Vitamins
Vitamin A (IU/d) 1333/2000 4685.61 (3643.16) 4236.85 (4388.96)a 5224.13 (2614.38) 6411.88 (3618.62)
344.63–17129.83 344.63–17129.83 3508.99–11927.39 2,332–16500.26
Niacin (mg/d) 8/12 25.32 (7.50) 25.52 (9.21) 25.08 (5.25) 22.45 (9.71)
6.13–40.41 6.13–40.41 12.76–30.12 10.32–43.25
Folic Acid (mcg/d) 200/300 445.09 (204.89) 445.22 (247.40) 444.93 (152.13) 410.96 (141.69)
122.47–1128.45 122.47–1128.45 241–761.48 177.37–638.59
Vitamin B6 (mg/d) .6/1.0 1.97 (.75) 1.94 (.86) 2.01 (.64) 1.99 (.58)
.48–3.38 .48–3.27 1.00–3.38 1.1–3.14
Vitamin B12 (mcg/d) 1.2/1.8 4.69 (3.03)a 3.48 (2.42)a,b 6.14 (3.15) 6.66 (2.04)
.3–14.15 .3–7.45 3.57–14.15 2.64–11.98
Vitamin D (IU/d) 200/200 198.62 (175.54)a 129.53 (138.89)a,b 281.53 (185.26) 319.86 (118.89)
6.74–572.21 6.74–497.05 80.63–572.21 78.66–518.12
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Bold value indicates statistically significant

a

Significantly different than control group, wilcoxon rank sum test, 2 tailed alpha P < .05

b

Significantly different than non selective eaters, wilcoxon rank sum, 2 tailed alpha P < .05

Comparison of Nutrient Adequacy

Table 3 examines the risk of inadequate dietary intake for the three groups by examining the proportion of subjects in each group who fail to meet DRI recommendations. Overall, selective eaters with autism were significantly more likely than typical controls to have inadequate intake of at least one nutrient (75% vs. 23%, P = .03). Although children with autism took in less protein on average, all but three of these subjects were at least meeting the low end of the acceptable macronutrient distribution range (AMDR) for protein intake. The three subjects who were not meeting the AMDR for protein intake were in the autism selective eater group, but this difference did not reach the level of statistical significance. Selective eaters with autism were more likely than typical controls to be at risk for inadequate intake for calcium (58% vs. 5%, P = .001), zinc (25% vs. 0%, P = .03), vitamin B12 (25% vs. 0%, P = .03) and vitamin D (58% vs. 5%, P = .001). Selective eaters with autism were more likely than non selective eaters with autism to be at risk for inadequate intake of calcium (58% vs. 0%, P = .02).

Table 3.

Impact of Selective eating on meeting dietary reference Intake recommendations

Measure Number (%) not meeting EAR/DRI
Autism selective eater (n = 12) Autism non-selective eater (n = 10) Typical development (n = 22)
Macronutrients (% below AMDR)
Energy 4 (33%) 0 (0%) 4 (18%)
Total fat 3 (25%) 0 (0%) 3 (14%)
Carbohydrates 2 (17%) 0 (0%) 0 (0%)
Protein 1 (8%) 0 (0%) 0 (0%)
Minerals(EAR)
Iron 1 (8%) 0 (0%) 0 (0%)
Calcium 7 (58%)a,b 0 (0%) 1 (5%)
Magnesium 3 (25%) 1 (10%) 5 (23%)
Zinc 3 (25%)b 0 (0%) 0 (0%)
Vitamins (EAR)
Vitamin A 2 (17%) 0 (0%) 0 (0%)
Niacin 1 (8%) 0 (0%) 0 (0%)
Folic Acid 3 (25%) 0 (0%) 3 (14%)
Vitamin B6 1 (8%) 0 (0%) 0 (0%)
Vitamin B12 3 (25%)b 0 (0%) 0 (0%)
Vitamin D 7 (58%)b 1 (10%) 1 (5%)
BMI (percentile)
 <15th percentile 0 (0%) 10 (0%) 1 (6%)
 <5th percentile 2 (17%) 0 (0%) 1 (6%)
Overall nutritional risk 9 (75%)b 3 (30%) 5 (23%)
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Bold value indicates statistically significant

a

Significantly different than autism-non selective eater group, Fischer’s exact test P < .05

b

Significantly different than typical control group, Fischer’s exact test P > .05

Discussion

As expected, children with autism had poorer food variety scores compared to age matched typical controls. Overall, typical children had a wider range of food choices than children with autism. Some children with autism appeared to be as flexible in their food choices as typical children, while others were much more limited and seemed to restrict their intake. This finding is similar to previously published data. Emond et al. (2010) determined that food variety was limited even prior to the diagnosis of autism in children as young as 15 months. The study also showed that food variety was limited across most subtypes of the autism spectrum. Bandini et al. (2010) found that autistic children had a more “limited food repertoire” compared to controls. Others have reported similar results (Williams et al. 2005, Ahearn et al. 2001; Schreck and Williams 2006).

Our findings are also consistent with previously published reports of micronutrient deficiencies in children with autism. Poor calcium intake has been consistently reported across studies of nutrient intake of children with autism (Bandini et al. 2010; Cornish 1998; Ho et al. 1997; Shearer et al. 1982; Lindsay et al. 2006; Johnson et al. 2008; Herndon et al. 2009). The risk of inadequate intake of Vitamin D intake found in this study had also been previously reported (Cornish 1998; Bandini et al. 2010; Lindsay et al. 2006). This data is especially concerning in light of the fact that many parents of children with autism limit or completely eliminate dairy from their child’s diet as part of the popularity of the gluten free casein free diet. Furthermore, data from Hediger et al. (2008) suggest that children with autism have poorer bone density than an age matched typically developing control group. Lower calcium and vitamin D intake may be partially responsible for the findings noted here and should be investigated further.

In our study, the group with autism had greater average intake of magnesium than the control group. Johnson et al. (2008) also found greater average intake in magnesium for preschool aged children with autism on 24-hour recalls and found that children with autism were less likely to be at risk for magnesium deficiency than controls. Foods high in magnesium include green vegetables, cashews, almonds, and whole, unrefined grains (Gerrior et al. 2004). While there is no tolerable upper limit for magnesium from food sources, the tolerable upper limit for magnesium intake from non-food sources is 110 mg for children less than 8 years old and 350 mg for children greater than 8 years old (Institute of Medicine 2001). It should also be noted that magnesium is a commonly used dietary supplement for children on the autism spectrum. A cautionary note should be given to parents that dietary intake alone is often sufficient, and that non-food sources should not exceed the tolerable upper limit. Children on supplementation should be monitored closely for side effects, which include diarrhea, hypotension, and decreased reflexes (Institute of Medicine 2001).

Also of note is that 11 of the 22 children in the autism group were above the tolerable upper limit for vitamin A intake, assuming all their Vitamin A was preformed, which is unlikely. However, some children with autism are using cod liver oil supplements, and commercial preparations can contain anywhere from 325 to 1,950 IU of Vitamin A. A cautionary note should be given to parents using cod liver oil, and dietary intake should be assessed carefully to assure that children are not at risk for vitamin A toxicity. Foods that contain Vitamin A include sweet potatoes, bell peppers, carrots, greens, cantaloupe, milk, and eggs (Gerrior et al. 2004). The symptoms of vitamin A toxicity include headache, seizures, vomiting, and abdominal pain acutely, and eczema, skin erythema, conjunctivitis, and musculoskeletal tenderness chronically (Udall and Greene 1992). Chronic Vitamin A toxicity has also been associated with premature epiphyseal closure and may be associated with osteoporosis (Udall and Greene 1992).

As predicted, this study suggests that selective eaters with autism are at greater risk for inadequate nutrient intake compared to non-selective eaters with autism and a control group. For several nutrients, specifically, calcium, zinc, vitamin D, and vitamin B12, selective eaters were at increased risk. Risk of nutrient deficiency was defined as not meeting EAR, which provides adequate nutrition for 50% of the population. The impact of chronic deficiency of calcium, vitamin D, vitamin B12 and zinc on symptoms of autism are not known. Nor is it known whether the specific deficiencies seen in this small group are an artifact of the particular food idiosyncrasies seen in the children studied. This paper does suggest that selective eaters with autism should have a more rigorous evaluation of their nutrient intake, possibly including a referral to a registered dietitian. Based on the findings in this and other studies, it could be argued that multivitamin, calcium and vitamin D supplementation be considered for children with autism who are selective eaters.

The reason for selective eating habits among children with autism has not been thoroughly investigated, but rigid adherence to rituals and routines seen as a core feature of autism is one hypothesized explanation. Sensory integration dysfunction may also play a role in problematic eating behaviors. Bennetto et al. (2007) found that children with ASD have problems correctly identifying taste and olfactory sensations suggesting that over or under responsiveness to sensory stimuli may also contribute to the high prevalence of feeding difficulties among this population. This is an area that requires further investigation. Children who are selective eaters are often referred to feeding programs which involve multidisciplinary teams including physicians, psychologists, occupational therapists and speech therapists. Ledford and Gast (2006) found that most of the literature on the effectiveness of these interventions is in the form of case reports or very small (n < 7) groups. Laud et al. (2009) found that intensive feeding interventions lasting an average of 47 days decreased problematic eating behaviors in 46 autistic children and at 3 years follow-up with 29 of the participants, eating problems had either stabilized where they had been at discharge from therapy or continued to improve.

Limitations of the Study

Our study was limited by small sample size. With a larger group, nutrients such as protein intake for selective eaters that were trending towards significance might have differentiated themselves. It should also be noted that standardized methods for measuring food variety do not exist, though a few methods have been tried in other studies (Bandini et al. 2010; Emond et al. 2010). While the methods in these studies were somewhat different, food frequency questionnaires were used to base calculations of food variety scores in each of these studies. The limitations of the use of food frequency questionnaires include recall bias. This methodology has been validated against 3 day diet recall with similar validity, but there is still an inherent tendency to over value foods eaten most recently.

Conclusions

Food variety was significantly lower among children with autism than typically developing children, which is similar to previously published data. Selective eaters appear to be at greater risk for serious nutritional deficiency than controls. It is possible that selective eaters with autism are not getting sufficient amounts of micronutrients, and these children can be screened by assessing their food variety. If food variety is found to be limited, further interventions with dietitians and therapists could be implemented to expand food variety and improve nutritional status. Future work is needed to validate food variety as a risk for nutrient intake deficiency and establish the range and severity of risk of these deficiencies among children with autism.

Acknowledgments

The authors would like to acknowledge the efforts of Twila Rogers, Study Coordinator, Cincinnati Children’s Hospital Clinical Trials Office. This study was was supported in part by USPHS Grant #M01 RR 08084 from the General Clinical Research Centers Program, National Center for Research Resources, NIH and in part by the Cincinnati Children’s Hospital Research Foundation.

Contributor Information

Michelle H. Zimmer, Division of Developmental and Behavioral Pediatrics MLC 4002, Cincinnati Children’s Hospital Medical Center, 3430 Burnet Avenue, Cincinnati, OH 45220, USA

Laura C. Hart, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA

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