*Article* **Dietary Patterns, Eating Behavior, and Nutrient Intakes of Spanish Preschool Children with Autism Spectrum Disorders**

**Julio Plaza-Diaz 1,2,3,†, Katherine Flores-Rojas 4,5,†, María José de la Torre-Aguilar 4,\*, Antonio Rafael Gomez-Fernández 4, Pilar Martín-Borreguero 6, Juan Luis Perez-Navero 4,7, Angel Gil 1,5,8 and Mercedes Gil-Campos 4,5**


**Abstract:** Eating behavior problems are characteristic of children with autism spectrum disorders (ASD) with a highly restricted range of food choices, which may pose an associated risk of nutritional problems. Hence, detailed knowledge of the dietary patterns (DPs) and nutrient intakes of ASD patients is necessary to carry out intervention strategies if required. The present study aimed to determine the DPs and macro-and micronutrient intakes in a sample of Spanish preschool children with ASD compared to typically developing control children. Fifty-four children with ASD (two to six years of age) diagnosed with ASD according to the Diagnostic Manual-5 criteria), and a control group of 57 typically developing children of similar ages were recruited. A validated food frequency questionnaire was used, and the intake of energy and nutrients was estimated through three nonconsecutive 24-h dietary registrations. DPs were assessed using principal component analysis and hierarchical clustering analysis. Children with ASD exhibited a DP characterized by high energy and fat intakes and a low intake of vegetables and fruits. Likewise, meat intake of any type, both lean and fatty, was associated with higher consumption of fish and dietary fat. Furthermore, the increased consumption of dairy products was associated with increased consumption of cereals and pasta. In addition, they had frequent consumption of manufactured products with poor nutritional quality, e.g., beverages, sweets, snacks and bakery products. The percentages of children with ASD complying with the adequacy of nutrient intakes were higher for energy, saturated fat, calcium, and vitamin C, and lower for iron, iodine, and vitamins of group B when compared with control children. In conclusion, this study emphasizes the need to assess the DPs and nutrient intakes of children with ASD to correct their alterations and discard some potential nutritional diseases.

**Keywords:** autism spectrum disorders; disabled children; food and nutrition; feeding behavior

**Citation:** Plaza-Diaz, J.; Flores-Rojas, K.; Torre-Aguilar, M.J.d.l.; Gomez-Fernández, A.R.; Martín-Borreguero, P.; Perez-Navero, J.L.; Gil, A.; Gil-Campos, M. Dietary Patterns, Eating Behavior, and Nutrient Intakes of Spanish Preschool Children with Autism Spectrum Disorders. *Nutrients* **2021**, *13*, 3551. https://doi.org/10.3390/nu13103551

Academic Editors: Roser Granero and Diego Redolar Ripoll

Received: 8 September 2021 Accepted: 8 October 2021 Published: 10 October 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

### **1. Introduction**

Autism Spectrum Disorders (ASD) are neurodevelopmental disorders characterized by disturbances in communication and social interaction and by the presence of restricted, repetitive patterns of behaviors, activities, and interests. These alterations are present from early childhood, although some difficulties may not manifest until the environment's demands exceed the child's capacity [1]. Most studies coincide with a significant increase in the prevalence of ASD, which does not seem to be explained by improving the detection systems. For 2016, ASD prevalence in the USA was 18.5 per 1000 (one in 54) children aged eight years, and ASD was 4.3 times as prevalent among boys as among girls [2]. It must therefore be considered a serious public health problem.

Children with ASD frequently have significant eating difficulties with a highly restricted range of food choices [3], and there is consensus that children with ASD have selective dietary patterns (DPs), food neophobia and sensory issues [4]. Indeed, the Diagnostic Manual-5 (DSM-5) now includes sensory symptoms in the diagnostic criteria for ASD, such as food selectivity [1]. Eating behavior problems are characteristics of ASD [5–7]. The dietary complications are more common among children with ASD than among the population during the first year of life from the time of introducing the complementary foods [8]. The rejection of solid foods is very frequent, and the introduction of foods with new textures, consistencies, and flavors tends to be difficult, so they preferentially consume the same foods in a repetitive manner [9,10]. Those behaviours do not seem to influence their growth long-term [4]. Still, they generate a great deal of family anxiety, becoming one of the main concerns of caregivers and family members [11,12]. Although these behaviours usually improve with time [13], the possible nutritional repercussions and the important social limitations are relevant and sensory goals should be included in treatment objectives for children with ASD [11].

The origin of eating behavior alterations is not entirely clear. Among some of the theories that can explain this phenomenon, the following stand out: (1) cognitive/behavioral alterations [14–16]; (2) sensory alterations [4,16,17]; and (3) gastrointestinal disturbances [18,19]. Eating problems in children and adolescents with ASD represent a concern for parents and caregivers and a potential cause of health issues. However, studies are diverse, presenting differences in the methodological steps, so their outcomes are hard to compare [20]. Some investigations have reviewed the consumption of children with ASD compared to those with typical development and determined some nutritional preferences of children with ASD. In general, they found stronger preferences for energy-dense foods like snacks, sweets, sugary beverages and juice in children with ASD. In contrast, children with ASD tend to eat less from food groups like vegetables, fruit and dairy products than children with typical development [21].

Without curative treatments and with these eating behavior alterations [22], the use of nutritional supplements and alternative medicine, which is widely used among families of ASD patients, has been greatly encouraged [23,24] when seeking clinical improvement. However, the use of nutritional supplements e.g., those containing omega-3 fatty acids [25], multivitamins, as well as a gluten-free casein-free diet [26], is not supported by the current scientific evidence, and it should not be generally recommended.

It has been suggested that the identification and development of nutritional assessment indicators that serve as early warning signs during routine practice are of interest [4]. Indeed, the present study aimed to determine the feeding behavior, DPs, and macro-and micronutrient intakes in a sample of Spanish preschool children with ASD compared to typically developing control children of the same age.

### **2. Material and Methods**

#### *2.1. Study Design and Subjects*

The present work is part of an observational and case-control study described elsewhere [27]. ASD patients from two to six years old in a specialized Unit for ASD in a third level hospital (Reina Sofia University Hospital, Cordoba, Spain) and diagnosed according

to DSM-5 criteria and validated by the Autism Diagnostic Observation Schedule (ADOS) score were recruited. A group of healthy children of similar age to that of the ASD group that came to the hospital for minimal surgery interventions with a normal detailed clinical history, general examination, anthropometric assessment, and control analysis to rule out any pathology was used as a control group. Both groups lived in the same urban area of Córdoba (Spain), with families in similar economic and sociocultural situations and close environmental exposure. Exclusion criteria were receiving medication for ASD comorbidities and any other pathology, be receiving or have received any nutritional supplement in the last 12 months; undertaking specific diets for therapeutic purposes in the previous 12 months e.g., celiac disease; and having a percentile higher than p97 or lower than p3 in the recommended tables of anthropometry of the Spanish child population [28,29].

The diagnosis of ASD was assessed following the clinical criteria of the DSM-5 and confirmed with the completion of the ADOS. An initial sample of 55 children with ASD (46 males and 9 females) between two and six years of age was recruited, following the inclusion criteria. During the recruitment phase, a male was excluded because he was diagnosed with celiac disease (*n* = 54). Fifty-seven healthy children, after normal results as noted above, were also included in the study as a control group.

The present study was approved by the Clinical Research and Bioethics Committee of the Hospital Reina Sofía, Cordoba, Spain. It was conducted in full compliance with the fundamental principles established in the Declaration of Helsinki. The data relating to the ASD patients were collected at the time they were recruited into the study. The recruited subjects were incorporated into the study after all the criteria for inclusion were fulfilled, and informed written consent was obtained from the children's legal guardians.
