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S146 HYMAN et al
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existing in the program so the total obtain an estimate of usual (or long the NHANES 2001–2002 What We Eat In
nutrient intake is not underestimated term) intake data from NDSR, data were America (WWEIA).26 A subset of nutrients
due to missing values. The NDSR anal- adjusted for day to day variability by important to bone health (vitamin D,
ysis was used to produce average nu- using the National Cancer Institute (NCI) calcium, phosphorus, and magne-
trient intakes for 160 nutrients. method.33,34 The NCI method models sium) was analyzed by using WWEIA
Box-Cox–transformed 24-hour intake 2005–2006.36 To compare macronutrient
Nutrition Variables observations as a function of observed intake and BMI data from our sample
The estimated average requirement (EAR) fixed-effect covariates, unobserved with those from the general US pop-
is the average daily nutrient intake level individual-level random effects, and ulation, we selected comparison groups
estimatedtomeettherequirementsofhalf within-individual error. The covariates of boys and girls of similar age from
of the healthy individuals in a group for (sequence and weekend versus week- NHANES 2007–2008.37,38
nutrients for which an RDA is scientifically day) are “nuisance effects” that are Participants in this study were matched
established. The cut point method, which explicitly adjusted for in the estimation on race, ethnicity, and income to the
reflects the proportion of individuals of usual intake. Complete details of the NHANES30 participants because of the
within a group with inadequate intake, NCI method and the SAS (SAS Institute potential impact of these factors on
was used to determine the percentage of Inc, Cary, NC) macros necessary to fit food choice.39 In most cases, 2 matches
individuals with intakes below the EAR.24 this model and to perform the Monte from the NHANES were found per study
Because of its skewed requirement dis- Carlo-based estimation of usual intake participant. The NHANES 2007–200837,38
tribution, the full probability approach distributions can be found at the NCI was the most recently analyzed sample
was used to determine the prevalence of Web site.34 The adjusted nutrient intake for BMI and macronutrients and was
insufficient iron intake.32 was then compared with age and gen- used for comparison by t test for
The average intake (AI) is the recom- der appropriate daily recommended continuous variables (nutrient intake)
mended daily intake based on observed intake (DRI) to examine nutritional and by x 2 tests for categorical varia-
or experimentally determined approx- sufficiency as established by the In- bles (BMI category). We used PROC
imations. It is used for nutrients where stitute of Medicine Food and Nutrition SURVEYMEANS and PROC SURVEYFREQ
data are insufficient to establish an EAR. Board.24 The DRIs are a set of reference in SAS 9.1 and appropriate 4-year sample
Intake levels above the AI imply a low values used to plan and assess nutri- weights.
prevalence of inadequate intake. State- ent intakes of healthy people and in-
ments regarding inadequacy cannot be clude the RDA, EAR, AI, and ULs. One RESULTS
made when intakes are below the AI. sample tests for proportions were Participants in this study were 367
Therefore, the percentage of children used to compare the proportion of our children with ASD (2–11 years); 295
with intakes greater than the AI was population above or below the DRIs as completed and returned the 3-day food
determined to reflect sufficiency for compared with population-based esti- records. A total of 72 participants
those nutrients.24 mates.26 All analyses were conducted agreed to participate in the study,
Tolerable upper limit (UL) is the highest by using SAS version 9.1 (SAS Institute completed BMI and initial forms, but
recommended daily intake level of Inc). did not complete the 3-day food
a nutrient likely to pose no risk of ad- The nutrient intake from diet was also records. Three 3-day food records were
verse health effects.24 It is used to as- compared with a general population of not analyzed because of reported ill-
sess the potential risk of excessive children collected through NHANES.35 ness in the recording interval. The nu-
intake. The percentage of children with The NHANES is a continuous survey of trition data are based on 252 records
intakes greater than the UL from food ∼5000 people per year from 15 na- analyzed at the time of manuscript
alone was determined. tionally representative communities. preparation. The demographics of the
BMI status was categorized by using It surveys the health and nutritional sample are described in Table 1.
NHANES criteria: ,5th percentile, un- status of adults and children in the
derweight; .85th percentile, over- United States by using a complex, strat- Special Diets and Nutritional
weight; and .95th percentile, obese. ified, multistage probability cluster Supplement Use
sampling design. The NHANES analysis A dietary restriction of gluten, casein, or
Data Analysis compared with the DRIs lags behind data processed sugars as an intervention for
The demographic data were summa- collection. The most current micronu- ASDs or food allergies/intolerances
rized with descriptive statistics. To trient dietary analysis available is from was reported for 18% of participants.
S148 HYMAN et al
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TABLE 3 Mean Macronutrient Intake of Children With ASD Compared With NHANES 2007–2008 and more parental control of foods
Matched Cohort
offered to younger children.
Nutrient Intake Age Range (y)a n DRI/AMDRb ASD Mean NHANES (mean)c
To address the accuracy and reliability
Energy, kcal 1–3 61 — 1375.9 1440.4
4–8 153 — 1683.9 1911.2***
of the nutrient data in this study, we
9–11 35 — 2003.2 2178.8 focused on 3 critical elements of study
Protein, g 1–3 61 13 42.94 49.72* design: the tools used to collect intake
4–8 153 19 50.85 64.11****
data, the completeness of the nutrient
9–11 35 34 68.29 73.38
% Protein 1–3 61 5–20 12.55 13.84** analysis software, and the appropri-
4–8 153 10–30 12.20 13.54**** ateness of the DRI and statistical
9–11 35 10–30 13.74 13.51 methods selected to interpret results.
% Carbohydrate, g 1–3 61 45–65 57.20 55.91
4–8 153 45–65 58.25 55.21**** Only 1 previous study8 used both the
9–11 35 45–65 56.40 56.78 recommended statistical analyses to
% Fat, g 1–3 61 30–40 31.94 31.54 assess insufficiency and nutritional
4–8 153 25–35 31.36 32.57
9–11 35 25–35 31.58 31.05 analysis software complete enough to
Fiber, g 1–3 61 19 10.17 9.09 provide accurate data. However, that
4–8 153 25 13.15 11.86 study of 53 children with ASDs and 58
9–11 35 31 16.74 13.75
controls reported on a limited num-
* P , .05; **P = .04; ***P = .001; ****P , .001.
a Nine through 11 years age category includes boys only because there were too few girls in this age category for analysis. ber of nutrients. The careful collec-
b AMDR is the range of intake for a particular energy source that is associated with reduced risk of chronic disease while
tion and analysis of the data on this
providing intakes of essential nutrients. If an individual consumes in excess of the AMDR, there is a potential of increasing the
risk of chronic diseases and/or insufficient intake of essential nutrients from other macronutrients.
ATN cohort provide for the most ac-
c NHANES population matched for age, gender, race/ethnicity, and socioeconomic status. curate description of what children
with ASDs eat in the United States to
date.
age for vitamins A, C, E, B12, and folate DISCUSSION The use of a matched NHANES control
and the minerals zinc and magnesium group further expands upon previous
Our data, on a large, geographically
(Table 4). work that compares the nutrition of
diverse cohort of children with ASDs,
identified lower than recommended children with ASDs to controls with
Micronutrients Examined by AI typical development.4,8,10,12,15,18 Al-
intakes of vitamins A, D, and K, as well
Consistent with the NHANES data, very as calcium, choline, fiber, magnesium, though many children with ASDs do
few children with ASDs consumed ade- phosphorus, and potassium from food not consume recommended levels of
quate fiber and potassium (Table 5). nutrient intake, this is consistent with
sources. These findings confirm pre-
There was no difference in the number intake of the general pediatric pop-
vious reports of insufficient intake of
of nutrients consumed in sufficient ulation in the United States. Most
calcium, fiber, zinc, and vitamins A, D,
amounts, above the EAR/AI, for chil- families of children with ASDs can be
dren in the different weight catego- and K.6–8,10,11,13,14,17–19 However, we did
counseled that although their child
ries. There was no difference in the not find that children with ASDs con-
may not be consuming the recom-
number of nutrients consumed in ad- sumed insufficient iron, B6, B12, or
mended diet, they may not differ
equate amounts by children with ASDs folic acid.6,7,11–14,19,20 Analysis of Vita- from children without ASDs in their
reported to be on restricted diets and min D intake was complicated by re- nutritional intake. No general rec-
those not on restricted diets (P = .55). cent changes in reference values,42 ommendation for vitamin or mineral
but over 3 quarters of the participants supplementation can be made based
Excess Intake had vitamin D intakes below the EAR. on the food intake data reported in
Many children with ASDs had nutrient Of note, ,3% of children in the this study. Specific nutrient supple-
intakes above the UL from food alone NHANES 2005–2006 sample had ade- mentation should be based on in-
such as copper, retinol (vitamin A), folic quate vitamin D intake.36 Patterns of dividual assessment.
acid, zinc, and manganese (Table 6). insufficient nutrient consumption by Although the purpose of this study was
Elevated intake of sodium was seen for age were identified. Younger children to examine the nutrient intake from
all age groups studied and was greater with ASDs were less likely to have in- food in children with ASDs as a group,
in the NHANES control group than in the sufficient nutrient intake. This may be there were isolated children with very
children with ASDs. due to lower absolute requirements restricted diets. Some of these children
Thiamine 1–3 0.4 ,3 because there were too few girls in this age category for
4–8 0.2 ,3 analysis.
9–13 0.2 ,3
Vitamin A 1–3 3.8 ,3
with ASDs given their selective, repetitive
Retinol activity equivalents 4–8 9.1 4***
9–13 17.4 13 intake.8,10–14
Vitamin B12 1–3 3.5 ,3 The risk for nutritional insufficiency of
4–8 4.3 ,3
9–13 5.0 ,3 children on restricted diets remains an
Vitamin B6 1–3 0.2 ,3 area of concern. Hediger et al21 found
4–8 0.4 ,3 decreased bone cortical thickness in
9–13 0.1 ,3
Vitamin C 1–3 2.4 ,3
children following a casein-free diet.
4–8 8.2 ,3**** Decreased calcium intake was not
9–13 10.2 8 reported by Cornish19 in a very small
Vitamin Db 1–3 86.9 NA
postal sample of children with ASDs on
4–8 89.2 NA
9–13 79.1 NA casein-free diets, however. Although
Vitamin E 1–3 35.1 80**** dairy products and fortified gluten-
4–8 42.0 80**** containing products are an important
9–13 55.9 97****
Zinc 1–3 1.0 ,3 source of nutrients, we did not find
4–8 6.3 ,3** a greater number of nutrient deficits in
9–13 8.4 ,3 children reported to be on special
NA, not applicable. *P = .04; **P = .02; ***P = .001; ****P , .001. diets. The ATN data record all special
a Nine through 11 years age category includes boys only because there were too few girls in this age category for analysis.
b DRIs for calcium and vitamin D changed from AI to EAR. Appropriate comparison is not available. diets as 1 category. Future analysis of
c Compared with 2005–2006 WWEIA.
these data will further examine this
d Reflects preformed niacin only and does not include contribution from tryptophan; therefore, there may be an over-
S150 HYMAN et al
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TABLE 6 Intake Above the UL for Although BMI is an important indicator the oldest age category to allow for
Micronutrients in Children With ASDs
Compared With WWEIA 2001–2002
for healthy weight, it is not necessarily a analysis of this group.
good indicator of nutrient status. Among
Nutrient Age Range (y)a ASD WWEIA
(% .UL) (%.UL) children with ASD, there was no differ- SPECIFIC RECOMMENDATIONS
Calcium 1–3 0.1 ,3
ence in the number of nutrients con- AND CONCLUSIONS
4–8 0.1 ,3 sumed in insufficient amounts across
9–13 0.2 NA weight categories. The data from this study have several
Copper 1–3 13.0 15 implications. The results indicate the
4–8 0.0 ,3
importance of nutritional surveillance
9–13 0.0 ,3 LIMITATIONS
Folic Acid 1–3 7.3 5 in primary care for all children, not just
(Synthetic) 4–8 7.3 4* Although this is the largest study of children with ASDs. The rate of nutri-
9–13 3.1 ,3 nutrient intake from food in children tional insufficiency is noteworthy in
Iron 1–3 0.0 ,3
4–8 0.1 ,3 with ASDs to date, volunteers were both the children with ASDs and the
9–13 0.0 ,3 predominantly white. It is possible that NHANES controls. Although there is
Manganese 1–3 39.9 NA volunteers for this study who com- not a simple nutrition screening tool
4–8 20.3 NA
9–13 2.5 NA
pleted the 3-day food record might have available for children with ASDs at this
Phosphorus 1–3 0.0 ,3 been either more concerned about time, clinicians should obtain a history
4–8 0.0 ,3 their child’s nutrition or had children of mealtime behavior and dietary intake
9–13 0.0 ,3
with more challenging behaviors. The in the context of well child care.45 Al-
Selenium 1–3 7.1 8
4–8 0.4 ,3 nutritional data are only as good as though a varied diet is typically associ-
9–13 0.0 ,3 the accuracy of the food record and the ated with better nutrition, fortification of
Sodium 1–3 65.1 83*** completeness of nutrition analysis foods given to children in this age range
4–8 70.6 94***
9–13 86.7 .97*** software. This is true for NHANES as may allow a less varied diet to meet most
Vitamin A 1–3 29.8 12*** well. Despite our efforts, inaccuracies in nutrient needs. Just because a child with
(Retinol) 4–8 9.0 ,3*** recording and the database may still ASDs has a limited variety does not mean
9–13 0.2 ,3
Vitamin B6 1–3 0.0 ,3
exist. Another limitation is the use of the that he or she needs additional vitamins
4–8 0.0 ,3 DRIs, which were established for physi- or a food supplement. Dietary assess-
9–13 0.0 ,3 cally healthy individuals with and with- ment needs to be considered individually,
Vitamin C 1–3 0.7 ,3
out developmental disabilities. Whether corroborated with anthropometric and
4–8 0.0 ,3
9–13 0.0 ,3 these recommendations are applicable laboratory data, and include consider-
Vitamin D 1–3 0.0 NA to children with ASDs is unknown and ation of referral to a registered dietitian
4–8 0.0 NA will require prospective study. Currently as necessary.
9–13 0.0 NA
Zinc 1–3 40.9 69*** they are the best available estimate of
4–8 13.0 22** nutrient needs of children. ACKNOWLEDGMENTS
9–13 0.1 ,3
This analysis was complicated by other We thank Nellie Wixom, RD, for her as-
NA, not applicable. *P = .04; **P # .01; ***P , .001.
a Nine through 11 years age category includes boys only issues affecting nutritional science in- sistance in data management; Diana
because there were too few girls in this age category for cluding differences in units between the Fernandez, MD, MPH, PhD, Stephen Cook,
analysis.
DRIs and food labels, the differences in MD, MPH, Peggy Auinger, MS, and Alanna
bioavailability of fortified nutrients, and Moshfegh, MS, RD, for their advice; and
overweight or obese. Underweight was the changing and extensive fortification the Cornell Dietetic Interns for help
more common for children with ASDs of foods. We attempted to address all of with literature review. We thank Harriet
aged 6 to 11 years than for the NHANES these concerns in the analysis. The Austin, PhD, Dana Barvinchak, Terri
controls. Preschool children with ASDs comparison of micronutrients to the Mitchell, Margaret Pauly, MS, RD, LD,
spend more time in therapeutic activi- NHANES from 2001 to 2002 was neces- Erin Bailey, Esther Hsueh, Dave Maloney,
ties, where snacks may be used to re- sary because this is the most recent Ann C. Meyers, MS, RD, LDN, Mindy
inforce participation, and where children complete NHANES/DRI comparison Reagan, RD, LD, and Nikki Withrow,
may have less opportunity or interest in available although BMI and macro- MS, RD for their tireless work with the
active play resulting in overweight. Chil- nutrients were compared with data families. We acknowledge the Autism
dren with typical development may have from 2007 to 2008. Specific analyses Treatment Network for use of the data,
more autonomy in food choices and ac- were matched by age categories; and we thank the families who partici-
cess to food when they reach school age. however, there were not enough girls in pated in the registry.
S152 HYMAN et al
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