Dietary intake and physical activity levels of male adolescents with Autism Spectrum Disorder (ASD) and normal to high Body Mass Index (BMI) – A case series study A. Humeyra Bicer, Marmara University, Faculty of Health Sciences, Department of Nutrition and Dietetics A. Aylin Alsaffar, Özyeğin University, School of Applied Sciences, Department of Gastronomy and Culinary Arts Objectives The study aims to determine the daily energy and nutrient intakes, eating behaviours and physical activity levels of male adolescents with autism spectrum disorder (ASD) and normal to high body mass index (BMI)-for-age and compares the values with an age-, gender- and BMI-for-age matched group consisting of typically developing adolescents. Adolescents with ASD in all age groups had significantly lower physical activity (expressed as METmin per week) when compared to typically developing counterparts (Table 4). Within the ASD group, both energy intake and physical activity levels (and their interaction) were found to be related to the BMI of the adolescents. No other factors studied seemed to explain the changes in the BMI (data not shown). Methods A subject group of 118 male adolescents (aged 12-18 years) with ASD and normal to high BMI-for-age is recruited from different autism rehabilitation centres in Istanbul, Turkey between December 2013 and December 2015. Control group included age range and gender matched-children (n=97) with normal to high BMI-for-age and with typical development (TDT). All participants (n=215) were weighed and measured in light clothing without shoes using a portable scale (accuracy 50 g; Seca874, Seca Ltd., Birmingham) and mobile stadiometer (accuracy 1 mm; Seca 217, Seca Ltd., Birmingham). Participants or their parents/caregivers were asked to complete four different questionnaires: (1) General questionnaire (2) Feeding assessment survey (3) 24-hour food recall and (4) International Physical Activity Questionnaire (IPAQ). Permission to conduct the study was granted by the Ethical Committee of the National Education Directorate of Istanbul and rehabilitation centres. All parents and caregivers who volunteered to take part in the study gave written informed consent. Table 3. Percent energy values provided by macronutrients (AMDRˠ)   % Protein % Carbohydrate % Fat BMI-for-age ASD TDT Normal 14.6 ± 3.5 15.6 ± 5.1 46.1 ± 7.4 43.2 ± 7.8 38.0 ± 7.3 40.7 ± 7.6 Overweight* 13.4 ± 3.3a 16.3 ± 5.2b 47.6 ± 6.8 45.1 ± 7.1 37.6 ± 6.7 37.4 ± 6.3 Obese 14.1 ± 3.5 15.1 ± 3.5 48.2 ± 6.9 45.1 ± 7.6 35.9 ± 7.0 38.4 ± 7.1 ˠ Acceptable Macronutrient Distribution Ranges (AMDR) for protein, carbohydrate and fat are 10-30%, 45-65% and 25-35%, respectively (Institute of Medicine, 2010). *Different superscripts in a row denote statistical significance (p < 0.05). TDT: Typical development. Discussion In accordance with our previous study (Bicer & Alsaffar, 2013), calcium and folate were the nutrients that the adolescents with ASD took inadequately. Current study also revealed inadequate intake levels of dietary fibre and vitamin D in the same group. Excess intakes of sodium and cholesterol continued to be emerging as a serious health concern in children and adolescents with ASD (Bicer & Alsaffar, 2013, 2015; Hyman et al., 2012; Marí-Bauset, Llopis-González, Zazpe-García, Marí-Sanchis, & Morales-Suárez-Varela, 2015). The current study showed that not only the adolescents with ASD but also typically developing adolescents had high intakes of these nutrients. It was interesting to see that the most AMDR values remained within the recommended range. This result suggested that the contribution of macronutrients to the adolescents’ diets was acceptable. Across BMI categories, physical activity levels of the adolescents with ASD differed significantly. Similar to the findings of previous research (Pan et al., 2015; Pan, Tsai, Chu, & Hsieh, 2011), current study confirmed that lower physical activity levels were associated with higher BMI-for-age values in adolescents with ASD. Results General characteristics of the study group can be seen in Table 1. Table 1. The age, gender and BMI classification of participants   BMI-for-age (ASD/Typical development) Normal weight Overweight Obese Number of adolescents (n) 30 / 31 33 / 34 55 / 32 Age, years (mean±SD) 15.6±1.6 / 16.2±1.8 15.4±1.6 /14.8±1.6 14.2± 1.7 / 14.9±1.4 Mother’s education, university or above (%) 50.0 / 26.1 45.4 / 29.4 41.9 / 34.4 Father’s education, university or above (%) 66.7 / 45.1 63.6 / 35.3 58.2 / 6.1 Child is an only child (%) 23.3 / 29.0 39.4 / 26.5 18.2 / 21.9 Eating behaviour (%) 26.2 /45.7 12.1 / 44.1 9.1 / 25.0 Food selectivity (%) 20.0 / 38.7 27.3 / 55.9 29.1 / 34.4 Constipation or diarrhoea (%) 36.7 / 6.5 45.5 / 0 36.4 / 3.1 Special diet (%) 0 / 9.7 9.1 / 11.8 5.5 / 3.1 Medication (%) 6.7 / 9.7 24.2 / 8.8 40.0 / 0 Table 4. Physical activity level of adolescents   BMI-for-age (ASD / Typical development) Normal weight Overweight Obese Number of adolescents (n) 30 / 31 33 / 34 55 / 32 Physical activity (METmin/week)(mean±SD) 393±204a / 4860±4700 114±198b,c / 3547±5847 104±290b,c / 2757±3346 *Bolded values within the same BMI-for-age category are different from each other (p<0.05). **Different superscripts in a row denote significant difference within a development group (p<0.05). Typically developing adolescents exhibited food selectivity at rates as high as or higher than the counterparts with ASD. Nutritional assessment of the adolescents with ASD and typical development (TDT) revealed similar prevalence of inadequacy for most nutrients. Dietary fibre, vitamin D, calcium and folate stood as the major nutrients that the adolescents were taking inadequately. Intake levels for nearly all micronutrients were insufficient (partially shown in Table 2). Excess intakes of sodium and cholesterol were observed in adolescents with ASD and TDT. Percent energy provided by protein, carbohydrates and fats (AMDR) did not present a clear trend across BMI-for-age categories either for the ASD or TDT group (Table 3). Conclusions In terms of nutrient intake, adolescents with ASD were not at a greater risk when compared to typically developing counterparts with similar BMI-for-age values. Diets of the both groups need to be improved. Excess intake of sodium and cholesterol in both groups of adolescents should be addressed. Meeting daily physical activity requirements can be as important as monitoring energy intake in adolescents with ASD. Acknowledgements We thank the participating families and the adolescents and the autism centers for their collaboration. We also thank ME Bicer for being an inspiration to us. Financial support This work has not received any funding. Conflict of interest The authors declare no conflicts of interest. Table 2. Percentiles of usual intake distributions of 14-18 year adolescents (n=87 with ASD- shown in black and n=78 with TDT- shown in red).   Percentile of usual intake distribution Nutrient EAR UL Mean 5th 10th 25th 50th 75th 90th 95th 99th Fibre (g) 38* n/a 24 12 13 17 23 28 35 42 53 18 7 8 30 31 Calcium (mg) 1100 3000 847 471 549 701 801 982 1184 1238 1442 648 229 273 439 598 872 1093 1186 1236 Sodium (mg) 2300ɫ 4515 2766 2950 3504 4221 5509 6141 7026 9568 4105 1474 1725 2990 4171 5112 6127 7009 8503 Vitamin D (µg) 10 100 2.2 0.2 0.3 0.6 1.4 2.5 3.6 4.3 11.5 3.0 0.4 0.8 3.2 3.9 5.9 20.7 Folate (µg) 330 800 291 167 184 224 280 336 398 441 538 261 111 132 254 339 393 415 473 Cholesterol (mg) 300ɫ 314 66 94 163 263 445 606 695 727 432 98 115 422 607 721 773 1015 References Bicer, A. H., & Alsaffar, A. A. (2013). Body mass index, dietary intake and feeding problems of Turkish children with autism spectrum disorder (ASD). Research in Developmental Disabilities, 34(11), 3978–87. Bicer, A. H., & Alsaffar, A. A. (2015). Dietary intake of adolescents with Autism Spectrum Disorder (ASD) and normal to high Body Mass Index (BMI). Integrative Food, Nutrition and Metabolism, 2(4), 231–238. Hyman, S. L., Stewart, P. A., Schmidt, B., Cain, U., Lemcke, N., Foley, J. T., … Ng, P. K. (2012). Nutrient intake from food in children with autism. Pediatrics, 130 Suppl, S145–53. Institute of Medicine. (2010). DRI Tables. Retrieved January 17, 2016, from http://iom.nationalacademies.org/~/media/Files/Activity Files/Nutrition/DRIs/5_Summary Table Tables 1-4.pdf Marí-Bauset, S., Llopis-González, A., Zazpe-García, I., Marí-Sanchis, A., & Morales-Suárez-Varela, M. (2015). Nutritional status of children with autism spectrum disorders (ASDs): A case-control study. Journal of Autism and Developmental Disorders, 45(1), 203–12. Pan, C.-Y., Hsu, P.-J., Chung, I.-C., Hung, C.-S., Liu, Y.-J., & Lo, S.-Y. (2015). Physical activity during the segmented school day in adolescents with and without autism spectrum disorders. Research in Autism Spectrum Disorders, 15-16, 21–28. Pan, C.-Y., Tsai, C.-L., Chu, C.-H., & Hsieh, K.-W. (2011). Physical activity and self-determined motivation of adolescents with and without autism spectrum disorders in inclusive physical education. Research in Autism Spectrum Disorders, 5(2), 733–741. EAR: Estimated average requirement, UL: Tolerable upper intake level This work has been recently published in Research in Autism Spectrum Disorders (2016) 31: 1-10. For further information please contact ayse.bicer@marmara.edu.tr