Althea Medical Journal. 2016;3(2)
319
Correlation between Calorie Intake and Nutritional Status of Autism
Spectrum Disorder in Children
Aryo Windaru,1 Fifi Veronica,2 Dian Marta Sari3
1Faculty of Medicine Universitas Padjadjaran, 2Department of Anatomy and Cell Biology Faculty
of Medicine, Universitas Padjadjaran, 3Department of Physical Medicine and Rehabilitation
Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung
Abstract
Background: Autism Spectrum Disorder (ASD) is a severe pervasive developmental disorder with prevalence
as high as one in sixty-eight children. Children diagnosed with ASD may have food intake problem and might
affect their nutritional status in the future. The objective of this study was to analyze the correlation between
total calorie intake and nutritional status of ASD children.
Methods: This cross-sectional study was conducted in Indigrow Child Development and Autism Center
involving 16 patients from October to November 2015. Total calorie intake was assessed by 24-hour food
recall and nutritional status was measured by Z-score. Correlation was analyzed using Spearman’s Rho.
Results: Overweight and obesity were found in 10 out of 16 ASD children assessed. Total calorie intake was
not significantly correlated with nutritional status of ASD children (r=0.021, p=0.940).
Conclusions: There is no significant relevance between total calorie intake and nutritional status in ASD
children at Indigrow Child Development and Autism Center. [AMJ.2016;3(2):319–22]
Keywords: Autism, calorie intake, nutritional status, Z-score
Correspondence: Aryo Windaru, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21,
Jatinangor, Sumedang, Indonesia, Phone: +62 85693260065 Email: aryowindaru@gmail.com
Introduction
Autism Spectrum Disorder (ASD) is a
neurodevelopmental disability that is usually
diagnosed before 3 years of age and is
characterized by deficits in social reciprocity
and in language skills that are associated with
repetitive behaviours and restricted interests.1
According to Centers for Disease Control and
Prevention (CDC), about 1 in 68 children
identified with ASD.2
Rogers et al.2 reported that 46–75%
children specifically diagnosed with ASD have
feeding, eating, and mealtime challenges.
Some study discovered that children with
autism have anomalous habits relating to food
and eating. These children are restricted by
food category and texture, and also refused
food more. Weighing from the risk, feeding
problems might affect the nutritional status of
ASD children themselves.3
One study conducted in Japan4 with 140
samples of Japanese children aged 7–18 years
with autism discovers 25% obesity among
those subjects. Another study supports this
evidence, Curtin et al.5 concluded children
with autism have 40% higher risk in suffering
from obesity. Overweight and obesity are
not trivial issues considering the effect in
increasing mortality of humankind. Various
complication may happen in consequence of
obesity which are type 2 diabetes mellitus,
hypertension, dyslipidaemia, and non-
alcoholic steatohepatitis.6 Despite of these
concerns, scarcity in research related to
nutritional status of ASD children is still a
problem.1 This study proposed hypothesis of
correlation between nutritional intake and
nutritional status on ASD children in Indigrow
Children Development & Autism Center,
Bandung.
Methods
Research design used in this study was cross-
sectional. Nutritional intake as independent
variable was obtained by conducting interview
to the parents of ASD patients who came to
the clinic. Subjects included in this study were
children with ASD from 2 to 17 years old at
Althea Medical Journal. 2016;3(2)
320 AMJ June 2016
Indigrow Child Development and Autism
Center from October to November 2015.
There were 16 children who met the inclusion
criteria. Every parent or guardian was given
an informed consent about the procedures of
this research and asked about the willingness
to participate in this study. Study was
conducted after obtaining Ethical Clearance
No: 485/UN.C1.3.2/KEPK/PN/2015 from
Health Research Ethics Committee, Faculty of
Medicine, Universitas Padjadjaran.
Calorie intake was acquired from 24-
hour food recall by interviewing the parents
of ASD children regarding foods and drinks
consumed a day before. Two separate
interviews were necessary to acquire calorie
intake in weekdays and weekends to minimize
bias. Calorie conversion guideline used in
this study was Indonesian Food Composition
Table (Indonesian FCT) which acquired from
Department of Medical Nutrition, Faculty of
Medicine, Universitas Padjadjaran.
Nutritional status was measured in Z-score,
a scoring system to assess differences of
child growth compared to references in the
same age and gender. Reference values of
Table 1 Nutritional Status based on Z-score
Category Z-score
Obese >2 SD
Overweight >1 to 2 SD
Normal ≥-2 SD to ≤1 SD
Underweight ≥-3 SD to<-2SD
Severe Underweight <-3 SD
Note: Based on Keputusan Menteri Kesehatan (Kepmenkes) Indonesia No: 1995/Menkes/SK/XXI/2010
Z-score and body mass index (BMI) in this
study were taken from Keputusan Menteri
Kesehatan (Kepmenkes) Indonesia No: 1995/
Menkes/SK/XXI/2010 tentang Standar
Antropometri Penilaian Status Gizi Anak.
Z-score was calculated after taking height and
weight measurement at the first visit which
transformed into BMI. Z-score was acquired
by calculating BMI together with age and
gender. Date of birth was taken in order to
determine the age of ASD patients at the first
visit. Correlation between calorie intake and
Z-score was analysed using Spearman’s Rho
regarding the calorie intake was not normally
distributed in Shapiro–Wilk test (p=0.003).
Results
Male participants were higher than female
participants (14 out of 2 children). Frequency
of overweight and obesity among ASD children
in Indigrow Child Development and Autism
Center was 10 out of 16 children.
Spearman’s Rho correlation test shows no
significance of correlation between calorie
Table 2 Characteristics of ASD Children Aged 2–17 years at Indigrow Child Development
and Autism Center
Characteristics Mean (SD) or Median (Min–Max) Frequency (n=16)
Gender
Males (n) 14
Female (n) 2
Total calorie per day (kcal) 1811.94 (1174.24–5073.95) 16
Z-score 2.76 (0.74) 16
Underweight (n) 0
Normal (n) 6
Overweight (n) 3
Obese (n) 7
Note: SD= standard deviation
Althea Medical Journal. 2016;3(2)
321Aryo Windaru, Fifi Veronica, Dian Marta Sari: Correlation between Calorie Intake and Nutritional Status of
Autism Spectrum Disorder in Children
intake and Z-score (r=0.021, p=0.940).
Discussion
This study showed that 14 of 16 participants
were male, this results congruent with a
previous study showing that autism occurs 4
to 5 times more in males compared to females.7
Seven out of 16 participants were obese,
but this study found that calorie intake was
inconsistent with nutritional status. This
phenomena can be explained in the way of
obesity caused by multifactorial factors not
just by a single etiology.8,9 Other factors like
physical activities, genetics, psychotropic
drugs, and sleep hygiene may also contribute
in manufacturing obesity. The most common
genetic alteration associated with ASD
is genomic duplications and deletions at
16p11.2 gene. Deletion in this region has
recently been shown to play role in early-
onset childhood obesity. The pediatric carriers
of 16p11.2 are 50% obese. Psychotropic drugs
are very commonly prescribed in children
with ASD. Studies about children with ASD
treated by risperidone discovered significant
weight gain versus placebo groups. Yet the
mechanisms by which antipsychotics cause
weight gain are not fully understood. Children
with ASD are often faced by sleep problems.
Several studies documented that overweight
in children is inversely correlated with sleep
duration. Physical activity and sedentary
behaviour are factors which contributed
in obesity development of children and
adolescent. Nonetheless, children with ASD
may be particularly challenged to engage in
physical activity in consideration of motor skill
difficulties.8
Evans et al.10 stated that ASD children have
higher levels consumption of energy dense
foods than typically developing children. Most
calorie intake of ASD children in this study
consists of snacks or instant noodles (14 out
of 16) according to the 24-hour food recall
and 6 out of 16 patients have higher calorie
diet based on age according to Recommended
Dietary Allowances: Harmonization in
Southeast Asia.
This study had several limitations; recall
bias may have occurred in this study (e.g.,
mothers’ reluctance to report “unhealthy”
food intake), which would underestimate the
true association between calorie intake and
nutritional status.
Methods such as 24-hour recall or
food diaries evaluate calorie intakes more
accurately, yet estimate short-term not long-
term intake.11 Some of the ASD children in
this study were hardly receive instructions
and cooperate in measurement which may
affect the measurement accuracy and caused
measurement bias.
The largest methodological limitation
presented among cross-sectional studies is a
confounding factor because measurement of
calorie intake only measured in one time only
and it is difficult to ascertain whether calorie
intake is contributing to nutritional status
of ASD children. However, cross-sectional
studies are vital in facilitating hypothesis
initiation to be further tested in observational
or experimental studies.12
Prospective cohort studies are better
equipped than cross-sectional studies to
adjust confounding factors but are still
observational in nature and thus vulnerable to
confounding factors as well.10 Total sampling
was used in this study, but still the sample was
lacking (N=16) and may not representative for
community.
In conclusion, this study does not show
any significant correlation between total
calorie intake and nutritional status of ASD in
children. This result is consistent with some
other studies stating that total calorie intake
is statistically insignificant toward nutritional
status.
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