English 150: Writing as Rhetoric Presleigh Keplinger Caterina Bernardini Research Paper December 8, 2013

How Does Diet Affect Autistic Individuals? According to the Merriam-Webster definition, autism, in general, is a developmental disorder that is variable in expression but is recognized and diagnosed by impairment of the ability to form normal social relationships, by the impairment of the ability to communicate with others, and by stereotyped repetitive behavior patterns. Jennifer H. Elder and others, authors of the article entitled The Gluten-Free, Casein-Free Diet in Autism: Results of A Preliminary Double Blind Clinical Trial find that the diagnosis of autism can be devastating to families who are often ill-equipped to meet the challenges of caring for a child with autism (413). Although there is no cure for this disorder, researchers have found that diet may play a role in influencing how autism affects each individual diagnosed and how families can help care for their autistic child by altering their diet. According to C. Gillberg, autism is conceptualized as a behavioural syndrome of multiple neurological injuries associated with a wide variety of medical conditions (61). Michael D. Kogen and others, authors of the article entitled Prevalence of ParentReported Diagnosis of Autism Spectrum Disorder Among Children in the US, implies that in 2008, the estimated prevalence of autism was 1 in 150, while today estimates

suggest rates as high as 1 in 91 (1395). With this growing prevalence of autistic individuals and no medical cure, researchers have studied various ways in which diet has influenced those diagnosed and the potential benefits from these diets. According to Jennifer H. Elder in her article The Gluten-Free, Casein-Free Diet in Autism: An Overview With Clinical Implications, One of the most popular, yet currently scientifically unproven, interventions for ASD [Autism Spectrum Disorders] is the GFCF [Gluten-free casein-free] diet (584). This diet eliminates all sources of gluten and casein in an individuals diet. Gluten is found in wheat, barley, rye, and certain oats, and casein is the main protein in dairy products. The removal of gluten and/or casein from the diet of people with autism, informs Paul Whitely and others, has, for many years, been reported by numerous parents as being related to significant improvements in behaviors associated with autism (47). Elder informs on a certain hypothesis theorizing the result of autistic symptoms and what gluten and casein do: It is hypothesized that some autistic symptoms (eg, stereotypical and ritualistic behaviors, perseveration, excessive activity, speech and language delays, and oddities) may be the result of opioid peptides formed from the incomplete breakdown of foods containing gluten and casein. Increased intestinal permeabilityallows these peptides to cross the intestinal membrane, enter the bloodstream, and cross the blood-brain barrier, affecting the endogenous opiate system and neurotransmission within the central nervous system. (584) In removing gluten and casein from an autistic individuals diet, autistic symptoms may possibly be lessened. This theory may explain the psychology and physiology of autism and effect for the gluten-free, casein-free diet.

The GFCF diet was first examined by Dr. Cade in 2000. Elder and others explain, Initially focusing on schizophrenia, Cade and colleagues conducted a series of studies to test Dohans hypothesis that schizophrenia is in some way associated with the absorption of exorphins contained in gluten and casein (414). After observing the dietary habits of South Pacific Islanders and inhabitants of New Guinea, Dohan found fewer and less severe cases of schizophrenia among those who did not eat gluten in their diet and believed there could be genetic defects in schizophrenia that result in an overload of peptides from milk protein (casein) and/or gluten (Elder 584). Following this initial work, Cade decided to test Dohans findings with children diagnosed with autism. Elder and others state that Cade conducted a study of 120 schizophrenic individuals and 149 individuals who met the Diagnostic and Statistical Manual of Mental Disorders (3rd edition) (DSM III) criteria for a diagnosis of autism (414). The children with autism were given a GFCF diet and within three months, parent and teachers reported improvements in behaviors in 81% of autistic children participating. Clearly, this diet is overall beneficial to a large majority. Elder describes that in a study conducted by Knivsberg and others in 2002, the experimental group [autistic individuals placed on GFCF diet] had significant improvement in autistic behavior, nonverbal cognitive level, and motor problems compared with those in the control group [autistic individuals not on GFCF diet] (585). However, in a study conducted by Elder and others on the effects of a GFCF diet in children with autism, grouped data [was] non-significant for each of the dependent variables but there was behavioral and language improvement seen in individual children (418). Overall, the GFCF diet still needs additional scientific research to help

determine its effectiveness on autism as a whole rather than improvements in certain individuals. There are, however, more benefits found than not. Another dietary intervention for autistic children is one similar to the GFCF diet, a gluten-free diet. In their article entitled A gluten-free diet as an intervention for autism and associated spectrum disorders: preliminary findings, author Paul Whiteley and others conducted a pilot study to provide a more substantial investigation into the short term effects of a gluten-free diet with children with autism and associated spectrum disorders (47). They explain, Gluten-free diets are traditionally used in mainstream medicine to treat gluten/wheat sensitivity or allergy and coeliac disease. They exclude foods which contain grains such as wheat, oats, barley, and rye (49). The study included 22 autistic participants who were placed on a diet free of gluten. After three months on the diet, parent and teacher observations reported improvement in autistic behaviors on a proportion of participants. Whiteley and others discuss the findings of this pilot study: Participants were described by parents as showing improvements in vocal and non-vocal communication (11/22), increased level of attention and concentration (10/22), decrease in episodes of hetero-aggressiveness (10/22) and autoaggressiveness (9/22), increased affection and affection-seeking behaviours (8/22), improved physical coordination and motor skills (8/22), increased awareness of self and environment (7/22), calmer disposition (7/22), and improvements in sleeping patterns (7/22). (50) At the end of this five month diet, 67% of parents of the participants rated the diet as leading to improvement in their childs autistic behaviors and 94%, a very large majority, stated that after the study concluded, their child would continue the gluten-free diet (55).

Although this is the only scientific study so far on a gluten-free diet as intervention for autistic childrens behaviors, there is clear evidence in support to it because of its benefits to autistic childrens behaviors. A Ketogenic diet (KD) is also becoming more prevalent in treating autistic behaviors. A Ketogenic diet is high in fat, low in carbohydrates, and adequate in protein. This diet forces the body to burn fat instead of carbohydrates. According to David N. Ruskin and others in their article entitled Ketogenic Diet Improves Core Symptoms of Autism in BTBR Mice, Given the ubiquitous presence of metabolic abnormalities in neurological disorders, including autism, metabolism-based therapies such as the KD are of great interest[and] several putative mechanisms mobilized by the KD may alleviate autistic symptoms (1). This diet was first introduced in 1921 by Wilder to act as therapy for epileptic seizures. In Application of a Ketogenic Diet in Children With Autistic Behavior: Pilot Study, Athanasios Evangeliou and others claim, the implementation of the ketogenic diet was based on clinical observation that [it] had beneficial effects in the control of epileptic seizures (113). Expanding on this research, Ruskin and others conducted a study to test the KD in BTBR mice. BTBR is a strain of mice that Ruskin and others describe as having an autism-like behavioral phenotype (1). They exhibit low sociability, high self-directed behavior, and reduced communication on a number of tests. After three to five weeks on the KD, BTBR mice became significantly and robustly social[and exhibited] decreased self-directed repetitive behaviors as quantified by time spent grooming (3). The BTBR mice placed on the KD showed much improvement as compared to BTBR mice in the control group. In conclusion, Ruskin and others report,

Our results suggest that a ketogenic diet improves multiple autistic behaviors in the BTBR mouse model. Therefore, ketogenic diets or analogous metabolic strategies may offer novel opportunities to improve core behavioral symptoms of autism spectrum disorders (1). In another study performed to test the effects of a Ketogenic diet on autism, Evangeliou and others conducted a one-year prospective study with thirty autistic children. The recommended dietdistribute[d] daily energy intake as follows: 30% of energy as medium-chain triglyceride oil, 30% as fresh cream, 11% as saturated fat, 19% as carbohydrates, and 10% as protein (114). Twenty-three patients, 76.6%, endured the diet, whereas seven could not tolerate it. Of the twenty-three remaining participants, five discontinued the diet after four to ten weeks due to lack of improvement. Of the eighteen autistic individuals that completed the study, 6.6% exhibited significant improvement in social behavior and interactions, stereotypy, speech, principality, cooperation, learning, and hyperactivity, with a reduction of more than twelve units on the Childhood Autism Rating Scale and were able to attend a non-mentally handicapped school. 26.6% showed average improvement and another 26.6% showed minor improvement. Evangeliou and others conclude The average improvement (based on all 30 patients) in terms of the Childhood Autism Rating Scale, was 4.77the result is highly significant (116). This experiment provides significant evidence that a KD is also effective in the treatment of autistic behaviors. The final diet to be discussed is one in which the gluten-free, casein-free diet and the ketogenic diet are combined into a gluten-free casein-free ketogenic diet. In their article entitled Autism and Dietary Therapy: Case Report and Review of the Literature,

Martha R. Herbert and Julie A. Buckley conduct a case report in which a child with autism and epilepsy was placed on a gluten-free casein-free ketogenic diet and showed significant improvements. They inform, A previously neurologically normal girl experienced sudden social, behavioral and language deterioration consistent with severe regressive autism over the course of a week, at the age of 4 years and eventually developed epileptic seizures (2). Fifteen months after her regression, her family placed her on a gluten-free casein-free ketogenic diet and noticed dramatic, immediate improvements in language and within two years, showed a 50-point improvement in her intelligence quotient. Her challenging behaviors resolved, as she was able to tell jokes and demonstrate a sense of humor (3). Although this is rare situation, the gluten-free casein-free ketogenic diet proved to significantly improve autistic behaviors in a child diagnosed with severe regressive autism. As the evidence of multiple studies conducted on behalf of a dietary intervention on autistic individuals conclude, diet plays a significant role in the treatment of autistic behaviors. Among the most common and effective diets are the gluten-free, casein-free diet, gluten-free diet, ketogenic diet, and the gluten-free casein-free ketogenic diet. Although these diets need further case studies and research in order to scientifically improve their effectiveness, a significant amount of reports have shown that autistic individuals have demonstrated an improvement in their autistic behaviors. As parents struggle to find a cure for their childs autism, dietary intervention provides them with a sense of hope that their autistic child may improve in their behaviors and will be able to some day maximize their potential.

Works Cited

Elder, Jennifer H. "The Gluten-Free, Casein-Free Diet in Autism: An Overview With Clinical Implications." Nutrition in Clinical Practice 23.6 (2008): 583-88. Print.

Elder, Jennifer H., Meena Shankar, Jonathan Shuster, Douglas Theriaque, and Sylvia Burns. "The Gluten-Free, Casein-Free Diet In Autism: Results of A Preliminary Double Blind Clinical Trial." Journal of Autism and Developmental Disorders 36.3 (2006): 413-20. Print.

Evangeliou, Athanasios, Ioannis Vlachonikolis, Helen Mihailidou, Martha Spilioti, and Astrinia Skarpalezou. "Application of a Ketogenic Diet in Children with Autistic Behavior: Pilot Study." Journal of Child Neurology 18.2 (2003): 113-18. Print.

Gillberg, Christopher. "What is Autism?" International Review of Psychiatry 2.1 (1990): 61-66. Print.

Herbert, Martha R., and Julie A. Buckley. "Autism and Dietary Therapy: Case Report and Review of the Literature." Journal of Child Neurology 00 (2013): 1-8. Print.

Kogen, Michael D., Stephen J. Blumberg, Laura A. Schieve, Coleen A. Boyle, and James M. Perrin. "Prevalence of parent-reported diagnosis of autism spectrum disorder among children in the US." Pediatrics 124.5 (2009): 1395-403. Print.

Ruskin, David N., Julia Svedova, Jessica L. Cote, Ursula Sandau, and Jong M. Rho. "Ketogenic Diet Improves Core Symptoms of Autism in BTBR Mice." Plos One 8.6 (2013): 1-6. Print.

Whiteley, Paul, Jacqui Rogers, Dawn Savery, and Paul Shattock. "A gluten-free diet as an intervention for autism and associated spectrum disorders: preliminary findings." Autism 3.1 (1999): 45-65. Print.