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Teresa
Binstock
Researcher in Developmental & Behavioral
Neuroanatomy
April 26, 2009
A recently published
study about bone development in autistic children (1) makes
preliminary but noteworthy points about exclusion diets and their
ramifications. Importantly, many autism parents report that their
autistic child improves in response to a food-elimination diet,
with gluten free (GF) and/or casein free (CF) being among the most
common (2). Working with clinicians, some parents purchase
food-hypersensitivity assays that further guide trials with an
elimination diet. The diets of autistic children are increasingly
studied (eg, 3-5), and the various findings suggest a lack of
proof for the efficacy of GFCF diets (6), even as a majority of
parents (N > 2500) report the GF and/or CF diet to have
beneficial effects in their autistic child (2).
ARI's
Parent Ratings data don't differentiate between GF and CF diets,
but most parents who responded (66% of > 2500) found an
exclusion diet to be helpful, whereas 3% reported adverse effects,
and 31% of parents perceived no effect of a GF and/or CF diet (2).
These diets had a ratio of 19 to 1 when comparing children who
improved versus children whose symptoms worsened. Further support
for the relevance of elimination diets is suggested by the
findings of Jyonouchi and colleagues, who have documented
food-related immune irregularities in children with autism (eg,
7-9).
The gap between autism-diet findings (eg, 6) and
parents' practical experience (2) may derive from methodologies
used in traditional medical research, wherein group comparisons
and statistical manipulations of data predominate, with
double-blind, placebo studies virtually considered to be
sanctified. However, "single-subject research" (eg,
10-12) may be more effective for evaluating elimination diets in
specific autistic children. The clinician's office and the child's
home may be better settings than study facilities located on
university campuses.
Given the background sketched above,
clinicians and parents are encouraged to peruse Hediger et al
2008, "Reduced bone cortical thickness in boys with autism or
autism spectrum disorder" (1). The study's findings are
accompanied by insights having significance for clinicians who
evaluate and treat autistic children.
"The effect of
casein-free diets was pronounced over these ages ([4-8 yrs] Table
4). The adjusted BCT [bone cortical thickness] of boys on
casein-free diets were lower, compared with the BCT of those on
unrestricted diets (p < .05). Adjusting for height, boys on
casein-free diets had average BCT % deviations of –18.9 ±
3.7%, almost twice that of boys on unrestricted diets (–10.5
± 1.3%, p < .04), although it should be noted that even
for boys on unrestricted diets the % deviation was still highly
significantly different from zero (p < .001). There was no
mitigating effect of calcium-containing supplement use." (1;
p852)
Note that autistic children not on a CF diet had bone
atypicality. The discussion by Hediger et al is well written and
thorough. Many possible factors influencing bone development are
considered, including but not limited to adrenarche and to
gastrointestinal and hormonal irregularities common in autistic
children (eg, 13-16). The roles of sunshine, daily activities, and
vitamin D are mentioned (1).
"...although a low
dietary intake of calcium and vitamin D from dairy sources
appeared to be a significant factor limiting bone development in
our study, it is probable that physical inactivity and/or lack of
sunlight exposure also contributed [to the BCT finding]."
The
researchers make clear that despite a large body of anecdotal
information about positive effects of elimination diets, a major
"double-blind, placebo control" study of restricted diet
in autism (3) had negative findings, which (as mentioned above)
may be derive from study design.
Hediger et al close with
sound counsel:
"Parents and health care practitioners
consider these diets to be at worst innocuous and without
significant adverse consequences. In light of these findings
[about reduced BCT], the potential for decreased bone development
and its effect on fracture risk in these children should be
considered when evaluating the risk-to-benefit ratio in treating
autism or ASD with a casein-free diet. Our results also suggest
that dietary intakes and bone development should be monitored in
children who are put on a casein-free diet." (2).
Indeed,
clinicians treating autistic children ought not presume that CF
diets are without ramifications. And, as Hediger et al have
described, autistic children not on a CF diet also tend to have
atypical bone development. Many factors are involved, not only
those mentioned hereinabove.
Substantive letters of
response to this brief critique of Hediger et al and supported by
citations will be considered for posting.
References:
1.
Reduced bone cortical thickness in boys with autism or autism
spectrum disorder.
Hediger ML et al. J Autism Dev
Disord. 2008 May;38(5):848-56.
National Institute of
Child Health and Human Development
Bethesda, MD
20892-7510, USA.
Bone development, casein-free
diet use, supplements, and medications were assessed for 75 boys
with autism or autism spectrum disorder, ages 4-8 years. Second
metacarpal bone cortical thickness (BCT), measured on hand-wrist
radiographs, and % deviations in BCT from reference medians were
derived. BCT increased with age, but % deviations evidenced a
progressive fall-off (p = .02): +3.1 +/- 4.7%, -6.5 +/- 4.0%,
-16.6 +/- 3.4%, -19.4 +/- 3.7%,-24.1 +/- 4.4%, at ages 4-8,
respectively, adjusting for height. The 12% of the boys on
casein-free diets had an overall % deviation of -18.9 +/- 3.7%,
nearly twice that of boys on minimally restricted or unrestricted
diets (-10.5 +/- 1.3%, p < .04), although even for boys on
minimally restricted or unrestricted diets the % deviation was
highly significant (p < .001). Our data suggest that the bone
development of autistic boys should be monitored as part of
routine care, especially if they are on casein-free diets.
2. Parent
Ratings
http://www.autism.com/treatable/form34qr.htm
3.
The gluten-free, casein-free diet in autism: results of a
preliminary double blind clinical trial.
Elder JH et al. J
Autism Dev Disord. 2006 Apr;36(3):413-20.
This study tested
the efficacy of a gluten-free and casein-free (GFCF) diet in
treating autism using a randomized, double blind repeated measures
crossover design. The sample included 15 children aged 2-16 years
with autism spectrum disorder. Data on autistic symptoms and
urinary peptide levels were collected in the subjects' homes over
the 12 weeks that they were on the diet. Group data indicated no
statistically significant findings even though several parents
reported improvement in their children. Although preliminary, this
study demonstrates how a controlled clinical trial of the GFCF
diet can be conducted, and suggests directions for future
research.
4. Dietary intake and parents' perception of
mealtime behaviors in preschool-age children with autism spectrum
disorder and in typically developing children.
Lockner DW et
al. J Am Diet Assoc. 2008 Aug;108(8):1360-3.
University of New
Mexico, Albuquerque, NM 87131
Parents of children with
autism spectrum disorder (ASD) frequently report that their
children have selective eating behaviors and refuse many foods,
which could result in inadequate nutrient intake. This preliminary
cross-sectional descriptive study investigated dietary intake and
parents' reported perception of food behaviors of 20 3- to
5-year-old children with ASD. Twenty typically developing children
matched for sex, age, and ethnicity were also studied as a
case-control comparison. Nutrient intake determined from 3-day
food records was adjusted for day-to-day variation to determine
the estimate of usual intake distribution for the two groups. This
distribution was compared with the Estimated Average Requirement
or Adequate Intake recommendations. The reported food behaviors
and use of vitamin or mineral supplements were compared for
matched pairs using the exact McNemar test. Nutrient intake was
similar for both groups of children, with the majority of children
consuming more than the recommended amounts for most nutrients.
Nutrients least likely to be consumed in recommended amounts were
vitamin A, vitamin E, fiber, and calcium. Children with ASD were
more likely to consume vitamin/mineral supplements than typically
developing children. Compared with parents of typically developing
children, parents of children with ASD were more likely to report
that their children were picky eaters and resisted trying new
foods, and they were less likely to describe their children as
healthy eaters or that they eat a variety of foods. Despite the
similar and generally adequate nutrient intake for the 40 children
in this study, parents of children with ASD had more negative
perceptions of their children's dietary behaviors.
5.
Does nutritional intake differ between children with autism
spectrum disorders and children with typical development?
Herndon
AC et al. J Autism Dev Disord. 2009 Feb;39(2):212-22. Epub 2008
Jul 4.
University of Colorado Denver, School of Medicine,
Aurora, CO 80045
Consumption of macro- and micronutrients
and food group servings by children with autism spectrum disorders
(ASDs; n = 46) and typical development (n = 31) were compared
using 3-day diet records. Children with ASDs consumed
significantly more vitamin B6 and E and non-dairy protein
servings, less calcium, and fewer dairy servings (p < .05). The
significantly lower dairy serving intake persisted after
controlling for child age and sex and parental dietary
restrictions, and excluding children on the gluten-free
casein-free (GFCF) diet. Large proportions of children in both
groups did not meet national recommendations for daily intake of
fiber, calcium, iron, vitamin E, and vitamin D.
6.
Gluten- and casein-free diets for autistic spectrum
disorder.
Millward C et al. Cochrane Database Syst Rev. 2008
Apr 16;(2):CD003498.
BACKGROUND: It has been suggested that
peptides from gluten and casein may have a role in the origins of
autism and that the physiology and psychology of autism might be
explained by excessive opioid activity linked to these peptides.
Research has reported abnormal levels of peptides in the urine and
cerebrospinal fluid of people with autism. OBJECTIVES: To
determine the efficacy of gluten and/or casein free diets as an
intervention to improve behaviour, cognitive and social
functioning in individuals with autism. SEARCH STRATEGY: The
following electronic databases were searched: CENTRAL(The Cochrane
Library Issue 2, 2007), MEDLINE (1966 to April 2007), PsycINFO
(1971 to April 2007), EMBASE (1974 to April 2007), CINAHL (1982 to
April 2007), ERIC (1965 to 2007), LILACS (1982 to April 2007), and
the National Research register 2007 (Issue1). Review
bibliographies were also examined to identify potential trials.
SELECTION CRITERIA: All randomised controlled trials (RCT)
involving programmes which eliminated gluten, casein or both
gluten and casein from the diets of individuals diagnosed with an
autistic spectrum disorder. DATA COLLECTION AND ANALYSIS:
Abstracts of studies identified in searches of electronic
databases were assessed to determine inclusion by two independent
authors The included trials did not share common outcome measures
and therefore no meta-analysis was possible. Data are presented in
narrative form. MAIN RESULTS: Two small RCTs were identified (n =
35). No meta-analysis was possible. There were only three
significant treatment effects in favour of the diet intervention:
overall autistic traits, mean difference (MD) = -5.60 (95% CI
-9.02 to -2.18), z = 3.21, p=0.001 (Knivsberg 2002) ; social
isolation, MD = -3.20 (95% CI -5.20 to 1.20), z = 3.14, p = 0.002)
and overall ability to communicate and interact, MD = 1.70 (95% CI
0.50 to 2.90), z = 2.77, p = 0.006) (Knivsberg 2003). In addition
three outcomes showed no significant difference between the
treatment and control group and we were unable to calculate mean
differences for ten outcomes because the data were skewed. No
outcomes were reported for disbenefits including harms. AUTHORS'
CONCLUSIONS: Research has shown of high rates of use of
complementary and alternative therapies (CAM) for children with
autism inc. luding gluten and/or casein exclusion diets. Current
evidence for efficacy of these diets is poor. Large scale, good
quality randomised controlled trials are needed.
7.
Innate immunity associated with inflammatory responses and
cytokine production against common dietary proteins in patients
with autism spectrum disorder.
Jyonouchi H et al.
Neuropsychobiology. 2002;46(2):76-84.
Department of Pediatrics,
University of Minnesota
OBJECTIVES: Children with autism
spectrum disorder (ASD) frequently reveal various gastrointestinal
(GI) symptoms that may resolve with an elimination diet along with
apparent improvement of some of the behavioral symptoms. Evidence
suggests that ASD may be accompanied by aberrant (inflammatory)
innate immune responses. This may predispose ASD children to
sensitization to common dietary proteins (DP), leading to GI
inflammation and aggravation of some behavioral symptoms. METHODS:
We measured IFN-gamma, IL-5, and TNF-alpha production against
representative DPs [gliadin, cow's milk protein (CMP), and soy] by
peripheral blood mononuclear cells (PBMCs) from ASD and control
children [those with DP intolerance (DPI), ASD siblings, and
healthy unrelated children]. We evaluated the results in
association with proinflammatory and counter-regulatory cytokine
production with endotoxin (LPS), a microbial product of intestinal
flora and a surrogate stimulant for innate immune responses.
RESULTS: ASD PBMCs produced elevated IFN-gamma and TNF-alpha, but
not IL-5 with common DPs at high frequency as observed in DPI
PBMCs. ASD PBMCs revealed increased proinflammatory cytokine
responses with LPS at high frequency with positive correlation
between proinflammatory cytokine production with LPS and IFN-gamma
and TNF-alpha production against DPs. Such correlation was less
evident in DPI PBMCs. CONCLUSION: Immune reactivity to DPs may be
associated with apparent DPI and GI inflammation in ASD children
that may be partly associated with aberrant innate immune response
against endotoxin, a product of the gut bacteria.
8.
Dysregulated innate immune responses in young children with autism
spectrum disorders: their relationship to gastrointestinal
symptoms and dietary intervention.
Jyonouchi H et al.
Neuropsychobiology. 2005;51(2):77-85.
Department of Pediatrics,
New Jersey Medical School
OBJECTIVE: Our previous study
indicated an association between cellular immune reactivity to
common dietary proteins (DPs) and excessive proinflammatory
cytokine production with endotoxin (lipopolysaccharide, LPS), a
major stimulant of innate immunity in the gut mucosa, in a subset
of autism spectrum disorder (ASD) children. However, it is unclear
whether such abnormal LPS responses are intrinsic in these ASD
children or the results of chronic gastrointestinal (GI)
inflammation secondary to immune reactivity to DPs. This study
further explored possible dysregulated production of
proinflammatory and counter-regulatory cytokines with LPS in ASD
children and its relationship to GI symptoms and the effects of
dietary intervention measures. METHODS: This study includes ASD
children (median age 4.8 years) on the unrestricted (n = 100) or
elimination (n = 77) diet appropriate with their immune
reactivity. Controls include children with non-allergic food
hypersensitivity (NFH; median age 2.9 years) on the unrestricted
(n = 14) or elimination (n = 16) diet, and typically developing
children (median age 4.5 years, n = 13). The innate immune
responses were assessed by measuring production of proinflammatory
(TNF-alpha, IL-1beta, IL-6, and IL-12) and counter-regulatory
(IL-1ra, IL-10, and sTNFRII) cytokines by peripheral blood
mononuclear cells (PBMCs) with LPS. The results were also compared
to T-cell responses with common DPs and control T-cell mitogens
assessed by measuring T-cell cytokine production. RESULTS: ASD and
NFH PBMCs produced higher levels of TNF-alpha with LPS than
controls regardless of dietary interventions. However, only in
PBMCs from ASD children with positive gastrointestinal (GI(+))
symptoms, did we find a positive association between TNF-alpha
levels produced with LPS and those with cow's milk protein (CMP)
and its major components regardless of dietary interventions. In
the unrestricted diet group, GI(+) ASD PBMCs produced higher IL-12
than controls and less IL-10 than GI(-) ASD PBMCs with LPS. GI(+)
ASD but not GI(-) ASD or NFH PBMCs produced less
counter-regulatory cytokines with LPS in the unrestricted diet
group than in the elimination diet group. There was no significant
difference among the study groups with regard to cytokine
production in responses to T-cell mitogens and other recall
antigens. Conclusion: Our results revealed that there are findings
limited to GI(+) ASD PBMCs in both the unrestricted and
elimination diet groups. Thus our findings indicate intrinsic
defects of innate immune responses in GI(+) ASD children but not
in NFH or GI(-) ASD children, suggesting a possible link between
GI and behavioral symptoms mediated by innate immune
abnormalities.
9. Evaluation of an association between
gastrointestinal symptoms and cytokine production against common
dietary proteins in children with autism spectrum
disorders.
Jyonouchi H et al. J Pediatr. 2005
May;146(5):605-10.
OBJECTIVE: To evaluate an association
between cytokine production with common dietary proteins as a
marker of non-allergic food hypersensitivity (NFH) and
gastrointestinal (GI) symptoms in young children with autism
spectrum disorders (ASD). STUDY DESIGN: Peripheral blood
mononuclear cells (PBMCs) were obtained from 109 ASD children with
or without GI symptoms (GI [+] ASD, N = 75 and GI (-) ASD, N =
34], from children with NFH (N = 15), and control subjects (N =
19). Diarrhea and constipation were the major GI symptoms. We
measured production of type 1 T-helper cells (Th1), type 2
T-helper cells (Th2), and regulatory cytokines by PBMCs stimulated
with whole cow's milk protein (CMP), its major components (casein,
beta-lactoglobulin, and alpha-lactoalbumin), gliadin, and soy.
RESULTS: PBMCs obtained from GI (+) ASD children produced more
tumor necrosis factor-alpha (TNF-alpha)/interleukin-12 (IL-12)
than those obtained from control subjects with CMP,
beta-lactoglobulin, and alpha-lactoalbumin, irrespective of
objective GI symptoms. They also produced more TNF-alpha with
gliadin, which was more frequently observed in the group with
loose stools. PBMCs obtained from GI (-) ASD children produced
more TNF-alpha/IL-12 with CMP than those from control subjects,
but not with beta-lactoglobulin, alpha-lactoalbumin, or gliadin.
Cytokine production with casein and soy were unremarkable.
CONCLUSION: A high prevalence of elevated TNF-alpha/IL-12
production by GI (+) ASD PBMCs with CMP and its major components
indicates a role of NFH in GI symptoms observed in children with
ASD.
10. Use of the single subject design for practice
based primary care research.
Janosky JE. Postgrad Med J. 2005
Sep;81(959):549-51. {free
online}
http://pmj.bmj.com/cgi/content/full/81/959/549
The
use of a single subject research design is proposed for practice
based primary care research. An overview of the rationale of the
design, an introduction to the methodology, strengths,
limitations, a sample of recent literature citations, a working
example, and possible clinical applications are presented.
11.
Case studies, single-subject research, and N of 1 randomized
trials: comparisons and contrasts.
Backman CL, Harris SR. Am J
Phys Med Rehabil. 1999 Mar-Apr;78(2):170-6.
Case studies,
single-subject research designs, and N of 1 randomized clinical
trials are methods of scientific inquiry applied to an individual
or small group of individuals. A case study is a form of
descriptive research that seeks to identify explanatory patterns
for phenomena and generates hypotheses for future research.
Single-subject research designs provide a quasi-experimental
approach to investigating causal relationships between independent
and dependent variables. They are characterized by repeated
measures of an observable and clinically relevant target behavior
throughout at least one pretreatment (baseline) and intervention
phase. The N of 1 clinical trial is similar to the single-subject
research design through its use of repeated measures over time but
also borrows principles from the conduct of large, randomized
controlled trials. Typically, the N of 1 trial compares a
therapeutic procedure with placebo or compares two treatments by
administering the two conditions in a predetermined random order.
Neither the subject nor the clinician is aware of the treatment
condition in any given period of time. All three approaches are
relatively easy to integrate into clinical practice and are useful
for documenting individualized outcomes and providing evidence in
support of rehabilitation interventions.
12.
Single-subject experimental designs: a practical research
alternative for practicing physicians.
Marvel MK, Amodei N. Fam
Pract Res J. 1992 Jun;12(2):109-21.
Single-subject research
designs offer a viable alternative to the more customary
group-comparison designs. The flexibility and practicality of
these designs make them particularly well suited for practicing
family physicians interested in testing their clinical hunches.
Three designs are described that are feasible in a practice
setting: ABAB (reversal), multiple-baseline, and the alternating
treatment design. Either visual inspection or statistical
approaches can be used to evaluate these designs. By being aware
of their limitations and by following simple practical steps, the
practicing physician can use these designs to improve care of
individual patients while simultaneously contributing to our
general knowledge.
13. Elevated levels of
growth-related hormones in autism and autism spectrum
disorder.
Mills JL et al. Clin Endocrinol (Oxf). 2007
Aug;67(2):230-7.
National Institute of Child Health and Human
Development, Bethesda MD
OBJECTIVE: Children with autism
are known to have larger head circumferences; whether they are
above average in height and weight is less clear. Moreover, little
is known about growth-related hormone levels in children with
autism. We investigated whether children with autism were taller
and heavier, and whether they had higher levels of growth-related
hormones than control children did. DESIGN: A case-control study
design was employed. PATIENTS: Boys with autism spectrum disorder
(ASD) or autism (n = 71) and age-matched control boys (n = 59)
were evaluated at Cincinnati Children's Hospital. MEASUREMENTS:
Height, weight and head circumference were measured. Blood samples
were assayed for IGF-1 and 2, IGFBP-3, growth hormone binding
protein (GHBP) and for dehydroepiandrosterone (DHEA) and DHEA
sulphate (DHEAS). RESULTS: Subjects with autism/ASD had
significantly (P = 0.03) greater head circumferences (mean z-score
1.24, SD 1.35) than controls (mean z-score 0.78, SD 0.93).
Subjects with autism also had significantly (P = 0.01) greater
weights (mean z-score 0.91, SD 1.13) than controls (mean z-score
0.41, SD 1.11). Height did not differ significantly between groups
(P = 0.65); subjects with autism/ASD had significantly (P = 0.003)
higher body mass indices (BMI) (mean z-score 0.85, SD 1.19) than
controls (mean z-score 0.24, SD 1.17). Levels of IGF-1, IGF-2,
IGFBP-3 and GHBP in the group with autism/ASD were all
significantly higher (all P < or = 0.0001) than in controls.
CONCLUSIONS: Children with autism/ASD had significantly higher
levels of many growth-related hormones: IGF-1, IGF-2, IGFBP-3 and
GHBP. These findings could help explain the significantly larger
head circumferences and higher weights and BMIs seen in these
subjects. Future studies should examine the potential role of
growth-related hormones in the pathophysiology of autism.
14.
Fetal testosterone and autistic traits.
Auyeung B et al. Br J
Psychol. 2009 Feb;100(Pt 1):1-22.
University of Cambridge,
Cambridge, UK
Studies of amniotic testosterone in humans
suggest that fetal testosterone (fT) is related to specific (but
not all) sexually dimorphic aspects of cognition and behaviour. It
has also been suggested that autism may be an extreme
manifestation of some male-typical traits, both in terms of
cognition and neuroanatomy. In this paper, we examine the
possibility of a link between autistic traits and fT levels
measured in amniotic fluid during routine amniocentesis. Two
instruments measuring number of autistic traits (the Childhood
Autism Spectrum Test (CAST) and the Child Autism Spectrum Quotient
(AQ-Child)) were completed by these women about their children
(N=235), ages 6-10 years. Intelligence Quotient (IQ) was measured
in a subset of these children (N=74). fT levels were positively
associated with higher scores on the CAST and AQ-Child. This
relationship was seen within sex as well as when the sexes were
combined, suggesting this is an effect of fT rather than of sex
per se. No relationships were found between overall IQ and the
predictor variables, or between IQ and CAST or AQ-Child. These
findings are consistent with the hypothesis that prenatal androgen
exposure is related to children exhibiting more autistic traits.
These results need to be followed up in a much larger sample to
test if clinical cases of ASC have elevated fT.
15.
Gastrointestinal symptoms in children with an autism spectrum
disorder and language regression.
Valicenti-McDermott MD et al.
Pediatr Neurol. 2008 Dec;39(6):392-8.
Few studies have
compared gastrointestinal problems in children with an autism
spectrum disorder with and without a history of language
regression. A cross-sectional study was conducted with structured
interviews in 100 children with autism spectrum disorder, using a
gastrointestinal questionnaire and a familial autoimmune
questionnaire. By parental report, children with language
regression more frequently exhibited an abnormal stool pattern
(40% vs 12%, P = 0.006) and had an increased family history of
celiac disease or inflammatory bowel disease (24% vs 0%, P =
0.001) and of rheumatoid arthritis (30% vs 11%, P = 0.03). Among
35 children with a family history of autoimmune disease, an
abnormal stool pattern was reported more frequently in those with
language regression (78% vs 15%, P = 0.001) than in those without.
An association was observed between children with language
regression, a family history of autoimmune disease, and
gastrointestinal symptoms. Additional studies are needed to
examine a possible shared autoimmune process.
16:
Relationship of dietary intake to gastrointestinal symptoms in
children with autistic spectrum disorders.
Levy SE et al. Biol
Psychiatry. 2007 Feb 15;61(4):492-7. Epub 2007 Jan 3.
BACKGROUND:
Gastrointestinal (GI) symptoms and abnormalities in stool
consistency are frequently reported by parents of children with
autism spectrum disorders (ASD). The purpose of this study was to
1) describe dietary intake of a cohort of children with ASD
compared with normative data and 2) determine whether GI symptoms
and stool consistency are related to dietary intake. METHODS: Data
from diet diaries of children (3-8 years) with ASD (n = 62) were
analyzed by a registered pediatric dietician to compare to RDA
standards for total calories, protein, carbohydrate, and fat.
Dietary intake was correlated with descriptors of stool
consistency using cumulative logistic regression methods. RESULTS:
Intake of calories, carbohydrates, and fat were in the average
range; protein intake was increased (211% of RDA). Reported
frequency of GI abnormalities, including abnormal stool
consistency (e.g., bulky or loose), was increased (54%). No
statistically significant relationships between stool consistency
and dietary intake were observed. CONCLUSIONS: In this sample,
there was a high rate of reported gastrointestinal symptoms,
despite lack of medical causes. Intake was adequate for calories
and carbohydrates and increased for protein. The children did not
exhibit excessive carbohydrate intake. There was no association of
nutrient intake to changes in stool consistency.
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