brian d. udell md faap medical director child development ...autism spectrum disorders fasting for...

www.childdev.org www.theautismdoctor.com

October19,2018

BrianD.UdellMDFAAPMedicalDirector

ChildDevelopmentCenterofAmericaDavie,FL33314954-873-8413

[email protected]

NutritionalEvaluationofthePatientwithDevelopmentalChallenges

•  Understandingthescopeofautism-MultiplecausesandMultiplepresentations

•  Evaluationofthemedicalstatusofthepatientwithdevelopmentalconcerns

•  Treatmentanddocumentationofprogress•  Nodisclosures•  ThispresentationdoesnotrepresentNovaUniversitypoliciesor

recommendations.

AutismSpectrumDisorders

Phenotypicpresentation

Environmentalevent(s)

Individualsusceptibility


?Cause(s)

AutismSpectrumDisorderDSMIVtoDSM5.0:

SpeechandLanguage

SocialMovement

EarlyandSignificant

SocialMovement

LearningCognitionReadingArithmetic

Seizures

Genetic

MetabolicEnvironment,

IntrinsicHypotonia,Processing

CNS

Repetitive

Apraxia

Hyperactivity

Skin

Sensory

Restricted

Immune

Eczema

AutoImmunityInflammation

Infections

Gutmicrobiome,nutrition

Aggression

Constipation/Diarrhea

Focus/Attention

AutismSpectrumDisordersTypesGenetic–FragileX,Rett’sS.,Trisomy21?,Copynumbervariations

Syndromes–Metabolicdisturbances,UnclassifiedGastro-intestinal

MostcommoninpracticeIfapersonactsliketheyhave‘antsintheirpants’,sometimestheyactuallydo!In8/11originallydescribedASDpatients(Kanner),disturbancesdocumented

Immunologic–Asthma,eczema,foodsensitivities,frequentearinfections,?vaccination

MicrobiomealterationsBirthcomplications–Cerebralpalsy,Genito-urinary,Gastrointestinal,“Premies’Metabolic&Nutritional–Vitamindeficiency,Lipidabnormalities,Pickyeaters,MTHFRBoyvs.GirlEarlyvs.Late


September1998

9males,7-10yoBoyswithautismappeartohavedietaryintakesdifferentthanthoserecommendedbythePyramidandRDAwithlowkcals,highproteinintake,lowconsumptionofmilk,vegetablesandhighconsumptionoffat.However,anthropometricmeasurementswereclosetothe50thpercentileexceptforgreaterWT/HT.Theinvestigatorssuggestmonitoringdietaryintakeandnutritioncounselingforchildrenwithautismtopreventloworexcessintake.

JournaloftheAmericanDieteticAssociationMEDICALNUTRITIONTHERAPYNutritionalAssessmentofChildrenwithAutismSCChapmanRDMJLucasMS,RD,LDSMcCammanMS,RD,LD


April2013

Parentquestionnaire,dietarylogof53ASDvs.NTChildrenwithautismexhibitedseveralabnormalitiesintermsofeatingbehaviorandgastrointestinalsymptoms.LevelsofvitaminsAandB6,ZnandCaintakeswere<80%ofthedietaryreferenceintakesinbothgroups.TheproportionsofvitaminCandCaintakedeficienciesintheautismgroupweresignificantlyhigherthanthoseinthecontrolgroup.

Nutritionalstatussurveyofchildrenwithautismandtypicallydevelopingchildrenaged4–6yearsinHeilongjiangProvince,ChinaCaihongSun,et.al.


April2013

SerumZnlevelwaslessthanthenormalreferencerangeinboththegroups.SerumCa,vitaminAandfolatelevelsinchildrenwithautismweresignificantlylowerwhencomparedwithchildrenwithoutautism.MeanBMI,weight-for-heightZ-score(ZWH)andBMIforageZ-score(ZBMIA)ofchildrenwithautismweresignificantlyhigherthanthoseofthetypicallydevelopingchildren.

Nutritionalstatussurveyofchildrenwithautismandtypicallydevelopingchildrenaged4–6yearsinHeilongjiangProvince,ChinaCaihongSun,et.al.


Thisassessmentisintendedtohelpfamilies,nutritionistsandresearchersmakearoughestimateofthequalityofdietandnutritionalsupplementationofapersonwithautism.

QualityofdietBasedonscoreparentmaymakemoreinformeddietarydecisions:

July2014


July2014


SelectiveeatingisacommoncharacteristicinASDchildren.Manyparentsimposegluten-freeand/orcasein-freedietsontheirchildren.ThesefactorsputASDchildrenatriskofnutritionaldeficiencyanddelayedgrowth.

January2015


80autisticchildren,dividedintotwogroups:3-5yearsand6-9yearsAutisticchildrensufferedinadequateintakeofsomemicronutrientssuchasvitaminDandC,calcium,folate,magnesium,phosphorus,zinc,andiron,somedeficiencieswerehighlysignificantespeciallyatolderage.Tailoringaspeciallydesignedbalanceddietwithappropriatemicronutrientsupplementationmayamelioratetheseverityofautismsymptomsandrelatedabnormalbehaviors.

June2015


July2015

Nutritionallyvulnerablepopulation

AcceleratedgrowthbutvariableBMIvs.NTResearchlackingaboutAAmetabolism,homocysteine,folate,vitaminsSelectiveeatingpatternsAspopulationages,problembecomesevenmorecomplicated

NutritionalStatusofIndividualswithAutismSpectrumDisorders:DoWeKnowEnough?SobhanaRanjan*andJenniferANasser


June2017

Studiesofgluten-orcasein-containingchallengefoodsreportednoeffectsonbehaviororgastrointestinalsymptomswithchallengefoods(insufficientSOE);1RCTreportednoeffectsofcamel’smilkonASDseverity(insufficientSOE).Harmsweredisparate.

PediatricsNutritionalandDietaryInterventionsforAutismSpectrumDisorder:ASystematicReviewNilaSathe,JeffreyC.Andrews,MelissaL.McPheeters,ZacharyE.Warren

CommonHistory&PhysicalExamination

DetailedPregnancy,LaborandDelivery,DevelopmentalMilestones,Familyhistory,Reviewofsystems,Observation,Interview

Initiallaboratoryevaluation*

Initialinterventions*

Closefollow-up*


InitialLaboratoryExamination

Blood–Completebloodcount,Comprehensivemetabolicprofile,Lipidpanel,VitaminD,Calcium,Magnesium,Thyroid,Folate,B12,MTHFR,GeneticFoodallergy,Heavymetals

Urine–peptidesfor‘leakygut’,toxins

Stool–comprehensivefordigestionandpathogens

Appropriateadditionaltesting



Protein&AminoAcidsLipidsCarbohydratesVitaminsMineralsTraceelements


Thetotalproteintestmeasuresthetotalamountoftwoclassesofproteinsfoundinthefluidportionofyourblood....Proteins,madeofaminoacids,areimportantpartsofallcellsandtissues.TwoclassesAlbuminisaproteinmadebyyourliver.

AffectsColloidOsmoticPressure–theabilitytokeepfluidinyourbloodstreamsoitdoesn'tleakintoothertissues.

Itisalsocarriesvarioussubstancesthroughoutyourbody,includinghormones,vitamins,andenzymes.GlobulinsareimportanttoimmunefunctionBesttomeasureserumANDurineaminoacidtoelucidateproblem


August2003

Plasmaaminoacidprofilesof36childrenwithASD

Tenofthechildrenwereonglutenandcaseinrestricted

Noaminoacidprofilespecifictoautismwasidentified.However,childrenwithautismhadmoreessentialaminoaciddeficienciesconsistentwithpoorproteinnutritionthananage/gendermatchedcontrolgroup.

Therewasatrendforchildrenwithautismwhowereonrestricteddietstohaveanincreasedprevalenceofessentialaminoaciddeficienciesandlowerplasmalevelsofessentialacidsincludingtheneurotransmitterprecursorstyrosineandtryptophanthanbothcontrolsandchildrenwithautismonunrestricteddiets.

Thehighrateoftryptophanandtyrosinedeficiencyinthisgroupisalsoofconcerngiventheirroleasneurotransmitterprecursors.

PlasmaAminoAcidsProfilesinChildrenwithAutism:PotentialRiskofNutritionalDeficienciesGeorgianneL.Arnold,SusanL.Hyman,RobertA.Mooney


February2003

PlasmaaminoacidlevelsweremeasuredinautisticandAspergersyndromepatients,theirsiblings,andparents.Theresultswerecomparedwithvaluesfromage-matchedcontrols.PatientswithautismorAspergersyndromeandtheirsiblingsandparentsallhadraisedglutamicacid,phenylalanine,asparagine,tyrosine,alanine,andlysine(p<.05)thancontrols,withreducedplasmaglutamineResultsshowthatchildrenwithautisticspectrumdisorderscomefromafamilybackgroundofdysregulatedaminoacidmetabolismandprovidefurtherevidenceforanunderlyingbiochemicalbasisforthecondition.

PlasmaAminoAcidLevelsinChildrenwithAutismandTheirFamiliesSarahAldredKieranM.MooreMichaelFitzgeraldRosemaryH.Waring


Laboratoryreportingismostlydetailingriskofarteriosclerosisandcoronaryrisk.Highmayindicatefamilialtendenciesandthereforelaterrisk,andmayhelpphysiciancounselparenttoaffordahealthierdiet.InASDpopulation,lowisimportantinCNSfunction–thebrainisafattyorganduetothedepositthatenablesconductionandinsulation.


July2006

Smith-Lemli-OpitzSyndrome(SLOS),ageneticconditionofimpairedcholesterolbiosynthesis,isassociatedwithautism.StudiedacohortofsubjectswithASDfromfamiliesinwhichmorethanoneindividualhadASD.AlthoughnosamplehadsterollevelsconsistentwithSLOS,19/100sampleshadtotalcholesterollevelslowerthan100mg/dl,whichisbelowthe5thcentileforchildrenoverage2years.Thesefindingssuggestthat,inadditiontoSLOS,theremaybeotherdisordersofsterolmetabolismorhomeostasisassociatedwithASD.

AbnormalitiesofcholesterolmetabolisminautismspectrumdisordersTierneyE,BukelisI,ThompsonRE,AhmedK,AnejaA,KratzL,KelleyRI.


Fastingforbestinformation.Higherthannormalglucoselevelsareanindicatorofpossiblediabetes,thoughdrugs,suchassteroidscaninflatethatnumber.Lowvaluesrepresentpoorglycogenstorageorrelease.Morefrequentfeeingcanbeagreatvaluetodeternegativebehaviors.Increasedpyruvate,lactate,ammoniaasindicatorsofmitochondrialfunction(abilitytoproducecellularenergy).Relatesclinicallytocoretoneweakness.


September2011

48childrenwithASDand53agematchedcontrols.

Levelsof82metabolites(53ofwhichwereincreased)weresignificantlyalteredbetweentheASDandthecontrolgroups.

Thelevelsofseveralaminoacidssuchasglycine,serine,threonine,alanine,histidine,glutamylaminoacidsandtheorganicacid,taurineweresignificantly(p≤0.05)lowerinASDchildren.ThelevelsofantioxidantssuchascarnosinewerealsoreducedinASD(p=0.054).

Furthermore,severalgutbacterialmetabolitesweresignificantlyalteredinASDchildrenwhohadgastrointestinaldysfunction.

Overall,thisstudydetectedabnormalaminoacidmetabolism,increasedoxidativestress,andalteredgutmicrobiomesinASD.

ImpairedCarbohydrateDigestionandTransportandMucosalDysbiosisintheIntestinesofChildrenwithAutismandGastrointestinalDisturbancesBrentL.Williams,MadyHornig,TimothyBuie,MargaretL.Bauman,MyungheeChoPaik,IvanWick,AshleeBennett,OmarJabado,DavidL.Hirschberg,W.IanLipkin


VitaminAlevels–especiallyinchildrenwhoexhibitvisual‘stimming’VitaminD3VitaminB2(Riboflavin)VitaminB5–(Biotin)VitaminB6(Pyridoxine)canhelpseizuresandhasbeenhelpfulinsomestudiesVitaminB12,B9(folates)importantindetoxification


RandomizedcontrolledtrialofvitaminDsupplementationinchildrenwithautismspectrumdisorderKhaledSaad,et.al

SupplementationofvitaminDwaswelltoleratedbytheASDchildren.Thedailydosesusedinthetherapygroupwas300IUvitaminD3/kg/day,nottoexceed5,000IU/day.Theautismsymptomsofthechildrenimprovedsignificantly,following4-monthvitaminD3supplementation,butnotintheplacebogroup.ThisstudydemonstratestheefficacyandtolerabilityofhighdosesofvitaminD3inchildrenwithASD.

November2016


VitaminAandvitaminDdeficienciesexacerbatesymptomsinchildrenwithautismspectrumdisorders.GuoM,et.al

197age-andgender-matchedcontrolchildren

Height-for-age,weight-for-age,andbodymassindexofthechildrenwithASDweresignificantlylowerthanthoseofthecontrolchildren.

Furthermore,higherproportionsofchildrenwithpickyeating,resistancetonewfoods,andeatingproblemswereobservedintheASDgroupwhencomparedwiththecontrolgroup.

Serumretinoland25-OHvitaminDlevelsinautisticchildrenweresignificantlylowerthanthoseinthecontrolchildren.

Additionally,VAandVDco-deficiencyimpactsmoreonthesymptomsanddevelopmentinautisticchildren.

January2018


ACaseofPartialBiotinidaseDeficiencyAssociatedWithAutismMarcoZaffanello,,et.al

Biotinidasedeficiencydiagnosedwhenthechildwasalmost4yearsofageTreatmentwith10mg/daydidnotamelioraateautismTreatmentsincebirthofyoungersiblingwithsamemetabolicproblem–nosignsorsymptoms

March2003

AutismSpectrumDisorderTreatmentofOxidativeStress

FolicAcid

MethylFolate

MTHFR

FolateCycle

OralB12Inactive

MB12Active

DetoxificationToxicMetals

FreeRadicals

SAMe

MethionineCycleMethionine SAH

Homocysteine

Cysteine

Glutathione

TransulfurationPathway

MS


CalciumMagnesiumIron


MagnesiumprofileinautismMirellaStrambiet.al

12autisticchildren(10boys,2girls),17childrenwithotherautisticspectrumdisorders(14boys,3girls),5girlswithclassicRettsyndrome,and14normalchildren(7boys,7girls)ofthesameage.NodifferencesinintracellularMgwerefoundbetweencontrolsandpathologicalsubjects;however,autisticchildrenandchildrenwithotherautisticspectrumdisordershadsignificantlylowerplasmaconcentrationsofMgthannormalsubjects(p=0.013andp=0.02,respectively).Manychildrenwithautisticspectrumdisordersrequirespecialdietarymanagement.Ifthesecasesarediagnosedatanearlystage,theycanbehelpedthroughdiet.

February2006


IronDeficiencyinAutismandAspergerSyndromeALatif,P.Heinz,R.Cook

Retrospectiveanalysisofthefullbloodcount,+/-serumferritin

96children(52withautismand44withAspergersyndrome)

Sixoftheautisticgroupwereshowntohaveirondeficiencyanaemia

Of23autisticchildrenwhohadserumferritinmeasured,12wereirondeficient.

OnlytwooftheAspergergrouphadirondeficiencyanaemia

Ofthe22childrenwhohadtheirserumferritinmeasured,onlythreewereirondeficient

Thisstudyshowedaveryhighprevalenceofirondeficiencyinchildrenwithautism,whichcouldpotentiallycompromisefurthertheircommunicationandbehaviouralimpairments.

March2002


Red-CellTraceMineralsinChildrenwithAutismJoanJoryandWoodyR.McGinnis

Redcellminerallevelsmeasuredin20childrenwithautismand15controls.

Childrenwithautismdemonstratedsignificantlylowerredcellselenium(p<0.0006)andhighermolybdenum(p<0.01)thanthecontrols.

Therewasatrendtowardlowerredcellzincandhighercobaltandvanadium,amongthechildrenwithautism.

Therewerenodifferencesinredcelllevelsofchromium,copper,manganese,ormagnesium.

Thesefindingsconfirmanearlierreportoflowredcellseleniuminautismandsupportarolefordecreasedtracemineralstatusinoxidativestressinautismthroughalterationofselenium-dependentantioxidantenzymesandincreasedlipidperoxidation.

2008


Supplementinterventionassociatedwithnutritionaldeficienciesinautismspectrumdisorders:asystematicreviewYong-JiangLi,et.al.

18randomizedcontrolledtrialsoffivesupplementswereincluded.B6/MgwasnothelpfulforimprovingASDsymptoms(sevenRCTs).TwoRCTsofmethylB12reportedsomeimprovementinASDseveritybuttheeffectsonthecorrectionofdeficiencieswereinconclusive.TwoRCTsofvitaminD3bothreportedincreasedlevelsofmean25(OH)Dinserumbutinconsistentresultsinbehavioraloutcomes.

October2018


Supplementinterventionassociatedwithnutritionaldeficienciesinautismspectrumdisorders:asystematicreviewYong-JiangLi,et.al.

Omega-3fattyacidsupplementationdidnotaffectASDbehaviorsbutmaycorrectdeficiencies(sixRCTs).OneRCToffolinicacidreportedpositiveresultsinimprovingASDsymptomsmeasuredbyvariousbehavioralscales.CurrentevidencefortheuseofsupplementsforcorrectingnutritionaldeficienciesinchildrenwithASDandtoimprovethesymptomsislittle.Morestudiesareneeded.

October2018


ComprehensiveNutritionalandDietaryInterventionforAutismSpectrumDisorder—ARandomized,Controlled12-MonthTrialJamesB.Adams,et.al

Randomized,controlled,single-blind12-monthtreatmentstudyofacomprehensivenutritionalanddietaryintervention.Participantswere67childrenandadultswithautismspectrumdisorder(ASD)ages3–58yearsand50non-siblingneurotypicalcontrolsofsimilarageandgender.Treatmentbeganwithaspecialvitamin/mineralsupplement,andadditionaltreatmentswereaddedsequentially,includingessentialfattyacids,Epsomsaltbaths,carnitine,digestiveenzymes,andahealthygluten-free,casein-free,soy-free(HGCSF)diet.

October2018


ComprehensiveNutritionalandDietaryInterventionforAutismSpectrumDisorder—ARandomized,Controlled12-MonthTrialJamesB.Adams,et.al

Therewasasignificantimprovementinnonverbalintellectualabilityinthetreatmentgroupcomparedtothenon-treatmentgroup(+6.7±11IQpointsvs.−0.6±11IQpoints,p=0.009)basedonablindedclinicalassessment.Basedonsemi-blindedassessment,thetreatmentgroup,comparedtothenon-treatmentgroup,hadsignificantlygreaterimprovementinautismsymptomsanddevelopmentalage.ThetreatmentgrouphadsignificantlygreaterincreasesinEPA,DHA,carnitine,andvitaminsA,B2,B5,B6,B12,folicacid,andCoenzymeQ10.

October2018

InitialNutritionalInterventionsAppropriatemineral,vitamin,aminoacid,lipidandcarbohydrateinterventionSpecializeddiets*ProbioticsOmega3fattyacids


DietaryInterventionsGlutenFree/CaseinFreeDiet

LowFODMAPS-(fermentableoligosaccharides,disaccharides,monosaccharides,andpolyols)

SpecificCarbohydrateDiet

GAPSDiet

Ketogenic

Feingold



April2006

15childrenaged2–16yearswithautismspectrumdisorderDataonautisticsymptomsandurinarypeptidelevelswerecollectedinthesubjects’homesoverthe12weeksthattheywereonthediet.Groupdataindicatednostatisticallysignificantfindingseventhoughseveralparentsreportedimprovementintheirchildren.

TheGluten-Free,Casein-FreeDietInAutism:ResultsofAPreliminaryDoubleBlindClinicalTrial




GAPSDiet

Ketogenic

Feingold



August2015

33childrenwithIBD,1weekdiet,1weekoff,1weekcrossoverInchildhoodIBS,alowFODMAPdietdecreasesabdominalpainfrequency.GutmicrobiomebiomarkersmaybeassociatedwithlowFODMAPdietefficacy.




GAPSDiet

Ketogenic

Feingold



October2014

Conclusions:ClinicalandmucosalimprovementswereseeninchildrenwithCD,whousedSCDfor12and52weeks.

ClinicalandMucosalImprovementWithSpecificCarbohydrateDietinPediatricCrohnDiseaseCohen,StanleyA.*;Gold,BenjaminD.*;Oliva,Salvatore‡;Lewis,Jeffery*;Stallworth,Angela*;Koch,Bailey*;Eshee,Laura†;Mason,David§




GAPSDiet

Ketogenic

Finegold





GAPSDiet

Ketogenic

Feingold



February2003

30ASDchildren,between4and10years,withautisticbehavior.

Thedietwasappliedfor6months,withcontinuousadministrationfor4weeks,interruptedby2-weekdiet-freeintervals.

Sevenpatientscouldnottoleratethediet,whereasfiveotherpatientsadheredtothedietfor1to2monthsandthendiscontinuedit.

Oftheremaininggroupwhoadheredtothediet,18of30children(60%),improvementwasrecordedinseveralparametersandinaccordancewiththeChildhoodAutismRatingScale.

Significantimprovementwasrecordedintwopatients,averageimprovementineightpatients,andminorimprovementineightpatients.

ApplicationofaKetogenicDietinChildrenWithAutisticBehavior:PilotStudyAthanasiosEvangeliou,MD,et.al.




GAPSDiet

Ketogenic

Feingold– www.feingold.org


Follow-Up

Somaticmeasurements,includingHeadCircumference

Laboratoryre-evaluationsofnutritionalstatus(vitamin&minerallevels,proteinandlipidlevels)asappropriate

Performanceinalldomains–Therapists’evaluation



Autismisamulti-factorialconditionwithmultiplecausesandpresentations.

Presentconventionalmedicaltherapiesarewoefullyinadequatetoaddressthegrowingnumberofpatients.

Evaluationofnutritionalstatusandappropriateinterventionscanassistthegoalofsymptomreduction.

Manytreatmentoptionshavebeenoffered-fewhaveundergonerigorousscientificscrutiny.Butuseofnutritionalproductsappearstocarryfewrisksandpotentiallygreatbenefit.

Pediatriciansareinthebestpositiontounderstandthecomplicatedscience,butmuststudyASDmoreseriously,inordertogivefamiliesusefuladvice.

www.childdev.org www.theautismdoctor.com

October19,2018


ChildDevelopmentCenterofAmericaDavie,FL33314

Ph [email protected]


ChildDevelopmentCenterofAmericaDavie,FL33314954-873-8413

[email protected]

brian d. udell md faap medical director child development ...autism spectrum disorders fasting for...

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