Eat Weight Disord (2014) 19:295301

DOI 10.1007/s40519-014-0137-0

ORIGINAL ARTICLE

Eating habits and dietary patterns in children with autism

Laura Diolordi Valeria del Balzo
Paola Bernabei Valeria Vitiello
Lorenzo Maria Donini

Received: 18 November 2013 / Accepted: 10 April 2014 / Published online: 1 July 2014
Springer International Publishing Switzerland 2014

Abstract The children with autism have feeding problems such as chewing, preference for the same food that
often are responsible for the nutrient imbalance. In this
study, we have analyzed the differences in food consumption (food frequency) and eating behavior (CEBI test)
between children with autism and their typically developing peers. A statistically significant difference was
observed between the two groups for the consumption of
milk, yogurt, pulses, rice, and fruit juices (p B 0,005). We
observed a significant difference in the analysis of CEBI
results when considering the 6- to 9.5-year-aged subgroup
with autism vs control subgroup (103.50 and 110.14,
respectively). The advices given by nutritionists have
proved crucial to improve eating habits in children with
autism, in the follow-up.
Keywords Eating behavior inventory
Food
consumption
Children with autism
Nutrition

Introduction
Children with autism often show difficulties in feeding.
Rigid and repetitive dietary patterns are frequently
observed in children with autism, and they may be
responsible for the nutrient imbalance; for example, the
L. Diolordi
V. del Balzo (&)
V. Vitiello
L. M. Donini
Department of Experimental Medicine, Research Unit of Food
Science and Human Nutrition, Sapienza University of Rome,
p.le Aldo Moro, 5, 00185 Roma, Italy
e-mail: valeria.delbalzo@uniroma1.it
P. Bernabei
Department of Pediatrics and Pediatric Neuropsychiatry,
Sapienza University of Rome, Rome, Italy

preference for the same food has been reported, limiting

the range of foods consumed and subsequently leading to
nutrient deficiencies in the long term [14]. Otherwise,
children with autism are used to choose the same food in
each meal and to eat it using the same piece of cutlery;
moreover, they may require the same presentation of the
food into the dish or they may prefer a liquid form or a soft
consistency, as puree or fruit juice [5].
Although children with autism are known to be highly
selective when choosing food, only a few studies currently
exist examining the adequacy of the diet in these patients
or comparing it to their healthy counterparts [1, 5, 6].
Interestingly, the lack of interaction with peers hinders
the learning of proper eating habits, such as the correct use
of cutlery or the ability to eat autonomously.
The combination of all these factors makes it more
difficult for a child with autism to maintain an adequate
nutrition status; moreover, such a condition may be exacerbated by frequent gastrointestinal disorders occurring in
the pediatric age [7, 8].
Some studies have reported that the adoption of a gluten- and casein-free diet may lead to the improvement
especially in the quality of sleeping and in terms of
aggressive behavior [9].
However, as studies in this field are very recent and still
at their early stages, it is not possible to state certainly
whether gluten- and casein-free diets are really beneficial
in children with autism.
Pending further investigations, parents of children with
autism often adopt diets that exclude certain foods, without
any advice from specialists, but simply relying on information found on websites. This approach further increases
the risks associated to an inadequate nutrition, rising the
likelihood that children with autism become nutrient
deficient.

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Aim of the study

The aim of this study was to assess differences in food
consumptions and eating behavior between children with
autism and their typically developing counterparts as well
as the possible effects of their nutritional choices on other
family members.
Methods
Subjects
Children with autism spectrum disorder were recruited
from the Centre for Autism, Department of Neurological
Sciences, Psychiatry and Rehabilitation of developmental
age, at La Sapienza University of Rome, from February
2009 onwards to December 2010.
The control group was composed of randomly selected,
age-matched children from pediatric facilities in central
Italy.
Exclusion criteria
Both children with sensory, visual, auditory or motor deficits were excluded from the study.

Methods
Autism was diagnosed according to the DSM-IV criteria
[10] as well as using tools and national and international
guidelines for the diagnosis of autism.
A medical record was completed with the following
data:
Personal data: age, gender, body weight, height and body
mass index.
Eating habits: a food frequency questionnaire was
prepared and validated. The food frequency questionnaire was used to detect the frequency of consumption of
the main traditional Mediterranean food groups as well
as other food items, such as sweet foods, drinks and
snacks. The frequency of consumption was compared to
that recommended by the LARN [11] for all the foods
considered to define the quality of eating habits. Foods
were divided into the following groups: fruit, vegetables,
potatoes, cereals (bread, pasta, rice and baked products),
meat, ham, fish, eggs, milk and yogurt, cheese, Parmesan
cheese on pasta, and fruit juices.
Eating behavior: the self-administered childrens eating
behavior inventory (CEBI) was used to detect any
difficult interaction between parent and child, as well as
the influence of the childs feeding behavior on family

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Eat Weight Disord (2014) 19:295301

meals [12]. The CEBI result is expressed by two scores,

the former regarding the eating behavior of the child, the
latter referring to the perception of the problem by the
mother. The score obtained for feeding behavior was
compared to the total eating problem box plot, which
provides reference values for the various abnormal
eating behavior diagnoses. The reference test score
ranges from 85 to 110 for group with autism, and from
78 to 93 for non-clinic group.
Rituals or constraints at mealtime were taken into
account also (e.g., putting toys or other objects on the
table, eating only in presence of certain conditions, and
being highly selective towards the consistency or the
color of food as well as the presentation of food into the
dishes).
Eating autonomy was evaluated to determine the degree
of autonomy and the pattern of meal consumption.
Intake of any medications or vitamins and mineral
supplements was considered: the parent was asked the
following questions to determine whether the child had
received any medication or supplements:
Is the child taking any medication (steroids, chelating
agents, antifungals or antimicrobials, antihistamines,
anti-inflammatories, fluoroquinolones) as well as melatonin, vitamin complexes, minerals or other supplements? Which and what doses?
Blood sampling and analysis of plasma amino acid
profile, minerals (calcium, sodium, potassium, chlorine, magnesium, phosphorus) and vitamins (vitamin
B12 and folic acid), screening for celiac disease
(anti-gliadin, anti-transglutaminase, and anti-endomysium antibodies) and specific IgE for food allergens (egg, tomato, casein, alpha-lactalbumin, betalactoglobulin, cocoa, whole milk, wheat and gluten)
were performed at the Umberto I- Sapienza University Hospital and at the Bambino Gesu Pediatric
Hospital, both in Rome.
Genetic analysis of the karyotype and the search for
gene mutations responsible for the fragile X syndrome
were performed.
Follow-up
A follow-up visit for children with autism was scheduled
12 months later to assess changes in eating habits and
behavior. A 5-month follow-up visit was scheduled in a
sample group of patients.
Data analysis
All parameters of the group with autism were compared
with the control counterpart.

Eat Weight Disord (2014) 19:295301

Table 1 Description of the
study groups

297

Group with autism

1st examination

Control group
1st examination

Group with autism

2nd examination

Control group
2nd
examination

Age (months) (mean sd)

58.3 22.2

62.4 24.6

73.0 24.8

67.2 22.8

Male (no)

27 (81.8 %)

17 (48.6 %)

25 (83.3 %)

16 (51.6 %)

Female (no)

6 (18.2 %)

18 (51.4 %)

5 (16.7 %)

15 (48.4 %)

Height (cm) (mean sd)

110.4 12.5

114.4 13.7

119.0 13.4

118.0 13.2

Weight (kg) (mean sd)

20.8 5.8

19.4 6.5

25.5 8.5

20.4 6.1

BMI (mean sd)

16.7 1.6

14.4 2.1

17.3 2.1

14.3 1.8

After verifying the normal distribution of data, the statistical analysis was performed by Students t test, and by
Chi-squared test for the comparison of proportions. Statistical significance was set at p value B0.05. Data were
analyzed using the SPSS for Windows 10.0 software
package (SPSS Inc., 19891999).

Table 2 Intake of medication, minerals, vitamins and other

Group with
autism %

Control
group %

Drugs (chelating, cortisone, antihistamine)

30

14

Mineral supplements

27

Vitamins

27

Other (melatonin, probiotics, etc.)

15

Results
The sample group consisted of 33 children with autism
spectrum disorders, while the control group included 35
age-matched healthy children. The first group was composed of 27 males (81.8 %) and 6 females (18.2 %) with a
mean age of 58.3 months. The control group was composed of 17 males (48.6 %) and 18 females (51.4 %) with a
mean age of 62.4 months (Table 1). The male/female ratio
was 4.5:1 in the group of children with autism. Seven
children with autism (21 %) were on an exclusion diet: one
child was on a milk protein-free diet, another one on a
gluten- and casein-free diet, while the remaining five
excluded lactose, gluten and casein from their diets.
Children with autism (39.4 %) were on chelating therapy, steroid, antihistamine or antifungal therapy, nine
subjects (27.3 %) were taking vitamin and mineral supplements, while five children (15.2 %) were taking probiotics, melatonin or cod liver oil (Table 2). In the control
group, five (14.3 %) children were on antihistamine and
corticosteroid therapy, whereas none was taking any vitamin or mineral supplement.
At the first visit, it emerged that vegetables were consumed twice a day, once a day and never by 7.5, 16.5 and
41 % of children with autism, and by 2.9, 27.5 and 6.9 %
of the control group, respectively.
The proportion of children who consumed fruit twice a
day was similar in both groups (42 % of the children with
autism as compared to 43 % of controls).
The consumption of pulses 23 times/week (24 % for
children with autism, 14 % for control group) and rice 45
times/week (12 % for children with autism, 0 % for control
group) yielded statistically significant differences between
the two groups (p B 0.005).

With respect to meat and fish, the frequency of consumption of these foods was different between the two
groups, even if it was not statistically significant: 39 % of
the children with autism ate meat 45 times a week as
compared to 69 % of their typically developing peers; fish
was consumed 23 times a week by 48.5 % of the subjects
with autism as compared to 54.3 % of controls. Moreover,
27.3 % of children with autism never ate fish as compared
to 0 % of their counterparts.
Dairy products were never consumed by 34.3 % of the
children with autism and 7.2 % of controls. A statistically
significant difference was observed between the two groups
for the consumption of both milk and yogurt (p B 0.005).
Indeed, milk and yogurt were consumed once a day by 18
and 33 % of the children with autism and by 49 and 5.7 %
of the control children, respectively.
Parmesan cheese was associated to pasta once a day by
42 % of the group with autism compared with 70 % of
controls, however, this difference was not statistically
significant. In addition, children with autism consumed
more snacks once a day than controls (33 vs 11 %) as well
as more fruit juices (24 vs 5.7 % twice a day and 27 vs
0 %, respectively; p B 0.005).
Biscuits were consumed twice a day by 36 % of the
children with autism vs 20 % of controls, whereas once a
day by 30 vs 49 %, respectively.
The abovementioned frequencies of food consumption
were compared to those obtained at the second visit,
showing the following both inter- and intra-groups
differences.
In particular, the twice a day consumption of fruit rose
from 43 to 58 % in controls, whereas the once a day

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Table 3 Food consumption in

relation to LARN servings in
children with autism and in
control group

LARN

Control group %

1st
examination

2nd
examination

1st
examination

2nd
examination

Fruit

2 Servings/day

42

40

43

58

Vegetables

2 Servings/day

7.6

6.7

1.45

Beans

1 Serving/day

42

33

54

61

Potatoes

23 Servings/
week

45

33

57

61

Cereal

5 Servings/day

40.37

37.8

42.5

41.8

Meat, ham, fish,

eggs

1 Serving/day

42.9

48.3

47.1

51.6

Milk/yogurt

2 Servings/day

25.5

20

27.35

33.8

Cheese

23 Servings/
week

45

40

71

73

Pasta parmesan

1 Serving/day

42

40

70

68

Fruit juice

2 Servings/day

24

30

5.7

consumption of fruit increased from 30 to 40 % in the

study sample.
Moreover, the proportion of children who never consumed raw vegetables dropped from 58 % at the first visit
to 50 %at the second visit (p B 0.005) in the group with
autism, in whom an increase in rice consumption was also
observed, especially in the 23 times/week frequency
(from 12 to 33 %).
Also worthy of note, a statistically significant increase in
fish as well as in meat 23 times per week consumption
was observed in children with autism (respectively, 48.5 vs
73.3 % and 30 vs 37 %, p B 0.005), while children with
autism who never ate fish dropped from 27.3 to 13.3 %
(p B 0.005).
The consumption of milk twice a day as well as that of
yogurt once a day decreased from 33 to 17 % and from 33
to 20 %, respectively.
The decrease of milk consumption was accompanied by
a drop in the consumption of biscuits twice a day from 36
to 23 %.
In the control group at the follow-up visit, the 45 times
per week consumption of meat decreased significantly
from 50 to 6.1 %, while the 23 times per week meat
consumption rose from 57 to 76 % (p B 0.005); daily
chocolate intake also dropped significantly from 26 to
6.1 % (p B 0.005).
The comparison of food consumption frequencies in
the group with autism and the LARN [9] recommendations (Table 3) revealed that all the considered foods
were generally consumed less frequently than recommended. At the follow-up visit, the consumption of
fruit increased in the control group, whereas in children with autism it decreased and that of fruit juices
increased.

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Group with autism %

Table 4 CEBI test: childrens eating behavior inventory

Control group
(M SD)

Group with autism

(M SD)

Total sample

103.49 8.48

103.21 9.67

25,9 years

103.49 8.46

101.35 8.84

69,5 years

103.50 10.51

110.14 10.09

1st Examination
Food problem score

% Item perceived as a problem

Total sample
25,9 years

14.75 5.30
16.13 15.10

22.08 16.19
20.33 15.69

69,5 years

12.10 10.10

28.57 17.61

2nd Examination
Food problem score
Total sample

104.61 4.24

103.33 2.12

25,9 years

105.11 8.42

102.55 9.20

69,5 years

103.83 10.81

106.00 10.15

% Item perceived as a problem

Total sample

13.99 3.54

17.81 10.61

25,9 years

15.45 15.36

17.35 15.32

69,5 years

11.69 10.07

19.29 15.05

Score in children with autism and in control group

The scores obtained at the CEBI showed that the proportion of children with eating disorders was similar in the
two groups (Table 4).
However, some differences emerged in the analysis of
CEBI results when considering subgroups of children on
the basis of different age classes. We observed a significant
difference in the 6- to 9.5 year-aged subgroup with autism
versus control subgroup (103.50 and 110.14, respectively)
and a difference between the first and second visit in

Eat Weight Disord (2014) 19:295301

299

Table 5 Plasma amino acids profile

Below (%)
Taurine

0.00

Above (%)
33.33

Aspartic acid

91.67

0.00

Threonine

26.67

0.00

Serine

33.33

0.00

Glutamic acid

0.00

28.57

Glutamine

0.00

6.67

Proline

0.00

0.00

Glycine

0.00

13.33

Alanine

13.33

20.00

Citrulline

0.00

26.67

Butyric acid
Valine

6.67
20.00

6.67
0.00

Methionine

6.67

0.00

Isoleucine

0.00

0.00

Leucine

13.33

0.00

Tyrosine

13.33

0.00

Phenylalanine

33.33

6.67

Ornithine

46.67

0.00

Lysine

26.67

0.00

Histidine

20.00

0.00

Arginine

46.67

0.00

Asparagine

0.00

26.67

Tryptophan

0.00

0.00

Percentage of children with autism with values below or above the

normal range

children with autism in the same age group (110.14 vs

106.00).
Some differences also emerged between the group with
autism and control group with regard to the perception of
the problem by the mother, and similarly to the aforementioned data, they were more pronounced in children
aged from 6 to 9.5 years.
A reduced perception of the problem was found out at
the second visit in the group with autism, though the difference was more marked in the 6- to 9.5-year-aged subgroup (rising from 28.57 to 19.29 %).
Differences observed in the behavior of the two samples
and in the perception of the problem by the mother were
not statistically significant.
The questions answered by the parents showed that
42 % of the children with autism presented constraints or
rituals at mealtimes, as compared to 11.4 % of their typically developing counterparts. Constraints and rituals
included eating exclusively, while watching TV or playing
with toys, or refusing to eat at the table or without their
mothers next to them, or wanting food cut into small pieces, all of the same size. Rituals in the control group also

included wanting the TV at mealtimes and bringing books

or toys to the table.
Family members of the children of the control group
were neither influenced nor copied these rituals. Dietary
habits and eating behavior were influenced in 12 % of the
families with a child with autism, whose family members
eliminated certain foods in 9 % of cases, as compared with
2.9 % of cases in the control group. No significant change
was observed in the rituals or the influence in familiar
eating behavior between the first and the follow-up
examination.
Data show that 63 % of the children with autism ate
autonomously without any help from familiar members, as
compared with 82 % of their peers. None of the children in
the control sample needed to be spoon-fed by an adult,
whereas 15 % of the children with autism needed to be
spoon-fed. The proportion of children who were not completely autonomus, sometimes requiring the spoon feeding,
was similar in both groups (21 % for children with autism
and 17 % for controls).
All parameters considered were within the normal range
of values. Vitamin and mineral deficiencies were not
observed, especially for plasma calcium levels, as children
who did not consume dairy products took calcium
supplements.
Plasma amino acid profile was analyzed just in 15
children with autism, highlighting marked alterations of
some amino acids (Table 5), especially of aspartic acid
levels that were below the normal range in more than 90 %
of the cases, and of glutamic acid concentrations, above the
normal range in 28.57 % of the cases.
Almost all the essential amino acid levels, i.e., threonine, valine, methionine, leucine, phenylalanine and lysine,
were below the normal range. Moreover, increased concentrations were observed for glycine, asparagine, citrulline and taurine.
The karyotype analysis was normal and the testing for
fragile X gene mutations was negative in all the children.

Discussion
The group with autism contained more boys than girls, the
male/female ratio being 4.5:1. This ratio is consistent with
that reported in other studies performed in children with
autism [13].
At the first visit, no marked difference emerged in body
weight between the two groups, whereas the children in the
control group were taller than their counterparts with
autism.
Subsequently, BMI was lower in the control group than
in the group with autism. This finding may be ascribed
to the fact that children with autism consume more

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energy-dense food than typically developing children as

well as less vegetables.
Previous studies showed that children with autism are
highly sensitive to bitter tastes leading to the refusal of
certain foods [5], and it could be a potential explanation for
the finding of a low intake of vegetables in the group of
children with autism in our study when compared to their
typically developing counterparts. By contrast, fruit was
found to be consumed in adequate amounts by both groups,
probably because of its texture and sweet taste.
All the children that we examined preferred meat to fish. It
is likely that children with autism do not eat fish, which is a
typical food of the Mediterranean diet, because of the fish
taste as well as the presence of fishbones, the latter leading
caregivers not to cook fish for children with autism. The
nutritionist provided advices to parents about preparing and
cooking fish, and underlined the importance of the nutrient
intake provided by this food, achieving an increase in the
consumption of fish at the follow-up examination.
Consistently with previous studies [6], the low intake
of dairy products in the group of children with autism is
due to misleading information responsible for the elimination of a category of food that is very important
during the pediatric age. In addition, unconventional
therapies that exclude gluten and casein from the diet of
children with autism are often adopted by parents, thus
exposing children to the risk of malnutrition [14]. The
elimination of foods containing gluten and casein is
based on the hypothesis that some symptoms of autism
(stereotyped behaviors, hyperactivity, etc.) may be due to
the presence of high levels of opioids in the central
nervous system (CNS) [15]. The suggested underlying
mechanism involves the products derived from the
incomplete digestion of gluten and casein, e.g., b-casomorphin and b-gladiomorphin, which are absorbed by the
intestinal membrane because of its increased permeability entering the bloodstream and crossing the bloodbrain
barrier [9]. It has been shown that these opioids may
affect the SNC by inhibiting its maturation and modulating neurotransmitter systems [1618].
The Defeat Autism Now (DAN) protocol [19] is prescribed by some pediatricians to encourage the use of
calcium supplements ensuring that daily requirements of
calcium are satisfied.
Children with autism consume larger amounts of foods
such as pasta, pizza and overall energy-dense foods, such as
biscuits, cakes and fruit juices. This finding is in accordance
with previous data in the literature, reporting that children
with autism show a preference for sweet taste and savory
foods [5], thereby tending to an excessive consumption.
The results of the current study highlight the presence of
eating and food-related problems both in children with
autism and in controls, as shown by the CEBI.

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The severity of these problems in the 6- to 9.5-year-old

group of children with autism was reduced at follow-up,
but remained unchanged in the control group.
The difference in scores between the first and second
visit in children with autism is likely linked to the psychiatric interventions on global behavior, and consequently
affecting also the eating features (e.g., sitting at the table),
as well as to the nutritionists advices to parents to adopt a
healthy diet for the child.
The difference described between the two groups in the
percentage of items perceived as a problem by the parents
reflected the difficulties usually experienced by parents of
children with autism. The perception of such problems
improved in the second visit, particularly in mothers of the
children with autism, demonstrating the effectiveness of
the interventions and the advices provided by health care
providers.
The presence of rituals at mealtimes that emerged in the
group of children with autism is consistent with previous
findings reported in several articles in the literature [5, 20,
21]. Moreover, accordingly to data by Schreck et al. [5],
our study highlighted the greater need for special tools and
food presentations in children with autism.
The presence of plasma amino acid abnormalities in
autism has been reported in several studies [22, 23], though
a single amino acid profile for autism has not been
described.
A limitation to our study was that the amino acid profile
was determined for a small number of the total subjects.
Low plasma levels of some essential amino acids, such as
valine, leucine, phenylalanine and lysine found in our study
were in agreement with data by Arnold et al. [22], who
reported also lower than normal levels of tryptophan,
whereas we did not find any alteration in this amino acid
concentrations.
Moreover, the negative results of the karyotype analysis
and the mutation analyses of the fragile X gene in our study
were in agreement with existing data [22]. Another limitation of this study was that even if the children were
recruited in a specialized center, their total number is relatively low. Furthermore, children with autism came to our
center from all over Italy, hence they do not always attend
the scheduled follow-up visits. The prevalence of autism in
Italy is (according to Eurispes data) (2006) [24] 610
children out of every 10,000 born.
Although our data add support to the existing literature
dealing with dietary habits in children with autism, further
research about nutrition of patients with autism is needed,
since the numerous obscure aspects surrounding this disease encourage parents to adopt their own choices
regarding food, which are usually found online and can
easily lead to malnutrition. Finally, nutritional intervention
plays a pivotal role in the correction of erroneous feeding

Eat Weight Disord (2014) 19:295301

habits, and long-term nutritional programs in children with

autism will provide more benefits.
Acknowledgments All authors have contributed to and read the
paper and have given permission for their name to be included as coauthors. No sponsor funding has been used. None of the authors have
received any financial support to develop this work.
Conflict of interest

None.

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