Transcript THE Gluten-FreE Casein

EFFECTIVENESS OF THE
GLUTEN-FREE, CASEIN FREE
DIET AS A TREATMENT
MODALITY FOR AUTISTIC
SPECTRUM DISORDERS
Honors Thesis Defense
April 8, 2013
Susanna Zammit
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Relevance to Dietetics:
 ↑prevalence of ASD
 Autistic children and GI problems
 Role of a dietitian
 Prevent nutrient deficiencies
 GFCF diet as possible MNT
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The Objective:
 To determine if the GCFC diet is effective
in ameliorating ASD core symptoms based
on past and present research.
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Overview:
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Prevalence of Autism
Characteristics of ASDs
Autism and GI Problems
Theories Behind GI Issues
The GFCF Diet
Logic Behind the GFCF Diet as MNT
As an Intervention
Interview Synopsis
Conclusion
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Prevalence of Autism
 ↑ 23% since 2009
 1980’s = 1 in 10,000
 2009 = 1 in 110
 Current = 1 in 88 (1 in 54 boys)
*Picture courtesy of AutismSpeaks.org
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Prevalence of Autism
Autism is a national health emergency. Our
hope is that the government will finally
declare it as such so that proper prevention,
treatments and resources will be put in
place.1
- Lori McIlwain
Executive Director
National Autism Association
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Characteristics of ASDs
 Autistic Spectrum Disorders
 Autistic Disorder
 Asperger syndrome
 Pervasive development disorder not otherwise specified
 Rett disorder
 Childhood disintegrative disorder
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Characteristics of ASDs
• Autistic Disorder
 Behavior
 Pathophysiology
 MRI Tests
 Smaller grey matter density4
 Less grey-matter density
 Larger brain size
 Cerebrum & corpus callosum
 Unusual sensory responses
 Angry outbursts
 Communication
 Lack of imagination in play
 Delayed speech devel.
 Social
 Avoidant eye contact
 Repetitive interactions
 Fail at friendships
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Characteristics of ASDs
* Photo courtesy of http://www.innovations-report.com/html/reports/medicine_health/report19951.html.
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Characteristics of ASDs
• Asperger Syndrome
 Behavior
 Pathophysiology
 Do not possess multisensory processing
deficit 6
 MRI Tests
 ↑white matter (in right hemisphere) 7
 Fewer differences with non-ASD 7
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NO delay in speech development 3
Anxiety
Unusual Communication
Social
 Avoidant eye contact
 Repetitive interactions
 Fail at friendships
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Autism and GI Problems
 1/3 have a GI disorder
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Duodenitis
Ileitus
Colitis
Dysmotility
Excessive Gut
Permeability
 Dybiosis
 Food Sensitivities
 & more
* Photo courtesy of
http://www2.medicine.wisc.edu/home/gastroenterology/gastroenterology
main
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Autism and GI Problems
 1996 ⇨ intestinal permeability ↑ by 43% 8
 ↑ absorption rate of short-chain fatty acids
 2001 ⇨ ↓plasma level of omega-3 fatty acids 8
 2005 ⇨ ↑oxidative stress level 8
 ↓antioxidant nutrients and enzymes
 2004 ⇨ inactive Vitamin B6↑by 75% 9
 ↑ antibodies in certain parts of the brain
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Autism and GI Problems
GI tract differences in ASD children
 2008 ⇨ Biopsy - 24 children 13
 ALL → mucousal lesions on ileum
 ALL → ileal lymphoid nodular
hyperplasia
 50% → nonspecific inflammatory
colitis
 2011 ⇨ stool tests,
bacterial cultures, 6-item
GI Severity Index etc. 11
 Correlation b/t severity of
autism & severity of GI
symptoms
Conclusion: There is a link b/t the brain & GI tract
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Autism and GI Problems
 AGAINST a link:
 ASD children have digestive problems aggravated
by exposure to wheat or dairy. 12
 Not a GI disease.
 2010 parental report based on data of siblings
from the Autistic Genetic Resource Exchange 14
 Refute own data
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Theories Behind GI Issues
1. Hyposecretion of Secretin
2. Link with Celiac Disease
3. The Leaky Gut Hypothesis (Opioid
Excess Theory)
4. Autistic Enterocolitis
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Theories Behind GI Issues
 Hyposecretion of Secretin
 Secretin ⇨ stimulates secretion
 Optimal pH of intestinal luminal fluid is 7-8
 In rats, injury to villi & s. albumin to the blood 15
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Theories Behind GI Issues
 Link with Celiac Disease
 1 in 100 births
 Presence of IgA & IgG anti-transglutaminase
autoantibodies in autistic children
 Brazil study – antigliadin autoantibodies
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Theories Behind GI Issues
 The Leaky Gut Theory
 Leaky mucosa allow food digestion products into
blood = antibody formation
 Exorphins = short-chain peptides into blood & brain
 Gliadorphin
 Casomorphin
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Theories Behind GI Issues
 Autistic Enterocolitis
 Andrew Wakefield → 1998
 Nonspecific ≠ Ulcerative colitis/Crohn’s
 FALSE 20
 Flawed control group
 Lack of validated and standardized definitions
 Speculative interpretation of results
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The GFCF Diet
 Recommended Foods:
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Amaranth
Arrowroot
Buckwheat
Corn
Flaz
Legumes
Millet
Nuts
Potato/Sweet Potato
Quinoa
Rice
Seeds
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Sorghum
Tapioca
Teff
Wild Rice
Oats*
Fish
Eggs
Dried Beans
Fruits*
Vegetables*
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The GFCF Diet
Gluten-Free
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Wheat
Barley
Rye
Beer
Bleu
Cheese
Hot Dogs
Coucous
Pickles
Twizzlers
Soy Sauce
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Pudding
Fried Foods
Candy
Thickners
Processed Lunch Meat
Modified Food Starch, etc.
Binders/Fillers in medications
Adhesives in Stamps/Stickers
Play Dough
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The GFCF Diet
Casein-Free
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All mammals milk → breastfeeding infants*
Milk
 Margarine
Butter
 Soy Cheese
Cheese
 Hot Dogs (texture)
Sour Cream
 Adhesives
Yogurt
 Paint
Ice Cream
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Logic Behind the GFCF Diet
 Elizabeth Strickland 25
 ‘Problem Feeders’
 Nutrient Deficiency=
lethargic &irritated
 36% ASD children = cow/soy milk protein intolerance
 ↑pro-inflammatory cytokines 24
 Fix the underlying problem
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As an Intervention
 2012 ⇨ Parental Report = Yes
 2009 ⇨ Treatment Selectivity = Yes
 2006-2008 ⇨ Scan-Brit = Yes, for short-term
 2009 ⇨ Systematic Review = NO
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As an Intervention
 Study-Design Flaws
 Parental Report= Caucasian Males, depend on
recall, and confirmation bias, not abiding the diet
 Selectivity Treatment= 1 participant, mother
collected data in journal, foods as bite sizes
 Scan-Brit = 24-month duration, no placebo
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As an Intervention
The Academy of Nutrition & Dietetics
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 January 2009 → many drawbacks to GFCF diet
not enough research
**Importance of the role of a dietitian
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Interview Synopsis
 Often refuse to eat gluten-free foods
 Hunger = agitation at meal times
 Inconsistencies in diet
 Parents’ lack of knowledge
 E.g. breaded chicken nuggets, fruit snacks, etc.
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Conclusion
1. Inconclusive findings
2. More research is needed
3. All studies done on children
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Conclusion
 Ideal Study
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Randomized, double-blind, controlled study
Follow-up > 4 yrs
Sample size > 100
Participants ages between 3-15 yrs
Monitored by a RD
Inclusion Criteria
 Dx of ASD
 Dx of GI disease based on biopsy
 Proof of misbehaving at meal times
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References
1.National Autism Association. Autism Prevalence Now 1 in 88 children, 1 in 54 boys.
National Autism Association Website. http://nationalautismassociation.org/autism-prevalence-now-1-in-88-children-1-in-54-boys/. Accessed February 20, 2013.
2. Baio J. Prevalence of Autism Spectrum Disorders. Centers for Disease Control and Prevention Website. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6103a1.htm.
Updated March
30, 2012. Accessed February 20, 2013.
3. Centre for Developmental Disability Health Victoria. Autism spectrum disorders fact sheet. http://www.cddh.monash.org/assets/fs-autism.pdf. Accessed February 10,
2013.
4. Craig MC, Zaman SH, Daly EM, et al. Women with autistic-spectrum disorder: magnetic resonance imaging study of brain anatomy. Br J Psychiatry. 2007; 191:224-228.
5. Abma D. Autistic brains work differently. The Vancouver Sun. April 4, 2011:B3.
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deficits in asperger syndrome. Autism Res. 2011; 4:383-388.
7. BMJ Group. Asperger’s syndrome pathophysiology. http://bestpractice.bmj.com/best-practice/monograph/707/basics/pathophysiology.html. Accessed March 15, 2013.
8. Balasubramanian S, Kendler B. Nutritional factors in autism: An overview of nutritional factors in the etiology and management of autism. Integrative Medicine.
2012;11:46-49.
9. Adams JB, Holloway C. Pilot study of a moderate dose multivitamin/mineral supplement
for children with autistic spectrum disorder. J Altern Complement
Med. 2004;10(6):1033-1039.
10. Souza NCS, Medonca JN, Portari GV, et al. Intestinal permeability and nutritional status in developmental disorders. Altern Ther Health Med. 2012; 18(2):19-24.
11. Adams JB, Johansen LJ, Powell LD, Quig D, Rubin RA. Gastrointestinal flora and gastrointestinal status in children with autism -- comparisons to typical children and
correlation with autism severity. BMC Gastroenterol. 2011; 11:22.
12. MacFabe, D. Autism and the digestive system. EP Magazine. November 2007.
13. Maffini V, Fornaroli F, Vincenzi F, et al. Autism and gastrointestinal disorders: A close relationship? Digestive and Liver Disease. 2008; 40(10):A93.
14. Russo AJ, Andrews K. Is there a relationship between autism and gastrointestinal disease? Autism Insights. 2010; 2:13-15.
15. White JF. Intestinal pathophysiology in autism. Exp Biol Med. 2003 June; 228:639-649.
16. Williams K, Wray JA, Wheeler DM. Intravenous secretin for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012 Apr 18; 4:CD003495.
17. Russo AJ. Relationship between celiac disease markers and gastrointestinal disease in children with autism. Immunology and Immunogenetics Insights. 2010 Mar 19:1.
18. Batista IC, Gandolfi L, Nobrega YK, et al. Autism spectrum disorder and celiac disease: no evidence for a link. Arq Neuropsiquiatr. 2012 Jan; 70(1):28-33.
19. Galiatsatos P, Gologan A, Lamoureux E. Austistic enterocolitis: Fact or fiction? Can J Gastroenterol. 2009 February; 23(2):95–98.
20. Deer B. Pathology reports solve “new bowel disease” riddle. BMJ. 2011;343:d6823.
21. Gluten-Free Diet. In: Fundukian LJ, ed. The Gale Encyclopedia of Medicine. Detroit: Gale; 2011; 3(4):1903-1907.
22. The Academy of Nutrition and Dietetics. Nutrition Care Manual®. http://nutritioncaremanual.org. Accessed March 7, 2013.
23. Truven Health Analytics, Inc. Patient Education Solutions. http://healthcare.thomsonreuters.com/patienteducationsolutions/carenotes/. Accessed March 9, 2013.
24. Jynouchi H, Sun S, Itokazu N. Innate immunity associated with inflammatory responses and cytokine production against common dietary proteins in patients with
autism spectrum disorder. Neuropsychobiology. 2002; 46:76-84.
25. Strickland E. Eating for autism: The 10-step nutrition plan to help treat your child’s autism, asperger’s, or adhd. Philadelphia, Pa: First Da Capo Press; 2009.
26. Pennesi CM, Klein LC. Effectiveness of the gluten-free, casein-free diet for children diagnosed with autism spectrum disorder: Based on parental report. Nutritional
Neuroscience. 2012; 0(0):1-7.
27. Wood BK, Wolery M, Kaiser AP. Treatement of food selectivity in a young child with autism. Focus on Autism and Other Developmental Disabilities. 2009 September;
24(3):169-177.
28. Whiteley P, Haracopos D, Knivsberg A, et al. The scan-brit randomized, controlled, single-blind study of a gluten- and casein-free dietary intervention for children with
autism spectrum disorders. Nutritional Neuroscience. 2010; 13(2):87-100.
29. Mulloy A, Lang R, O’Reilly M, Sigafoos J, Lancioni G, Rispoli M. Gluten-free and casein-free diets in the treatment of autism spectrum disorders: A systematic review.
Research in Autism Spectrum Disorders. 2009.
30. Marcason W. What is the current status of research concerning used of a gluten-free, casein-free diet for children diagnosed with autism? JADA. 2009.
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Thank you…
Any questions?
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