Introduction with ASD. It also critically explored the strategies

Introduction

Parents of children diagnosed with autism spectrum
disorders (ASD), tend to opt for alternative intervention for their children,
for example, the use of a gluten-free, casein-free diets, which they perceived
as risk free, to improve the cognitive-behavioural function of their children
with ASD. The main focus of this essay is to discuss the most recent advances
in gluten-free research and the evidences that argued for or against the use of
a gluten-free, casein-free diets, especially for children who are diagnosed
with ASD. It also critically explored the strategies used, the challenges encountered,
and the emotional impact experienced by people who followed a gluten-free diet,
as evidenced by past research studies. A systematic review of research papers published
from 1970 to date indicated that most studies conducted on children with ASD who
are following a gluten-free diet were mostly tested on randomized controlled
trials, with small sample sizes. Hence, it lacks validity and sound scientific
evidence to conclude the effectiveness of adopting a gluten-free diet as a form
of intervention. Future research on a larger scale is recommended (O’Shea,
Arendt, & Gallaghar, 2014; Zarkadas, Dubois, McIsacc, Cantin, Rashid, Roberts,
La Vieille, Godefroy, & Pulido, 2013; Mari-Bauset, Zazpe, Mari-Sanchis,
Llopis-Gonzalez, & Morales-Suarez-Varela, 2014).

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Description
and Definition

Autism spectrum
disorders (ASD) has been on the rise for the past 30 years and is becoming
prevalent, affecting 1 in every 68 persons in United States. It is a highly complex
disorder with multiple causes and various treatment approaches to treat only
the symptoms as autism is not curable. Children with autism are characterised
by a spectrum of neurological developmental disorders that manifest in early
childhood. They include persistent deficits in social communication and social
interaction, along with restricted, repetitive patterns of behaviour,
interests, or activities, such as stereotyped or repetitive speech, motor
movements or fixative interest in certain object or task. A variety of genetic,
environmental and immunological factors could also affect multiple systems,
especially the
cognitive-behavioural function of the person with ASD. In past epidemiological
studies of prenatal development, metabolic and nutritional factors have been
identified as one of the contributing risks of autism for the newborn babies (Matelski,
& Van de Water, 2016).

The ‘opioid excess
theory’ could best explain ‘gluten and casein intolerance’ in persons diagnosed
with ASD. According to Lange, Hauser & Reissmann (2015), when gluten (from
wheat) and casein (from dairy products) are consumed into the body, they are
metabolized to ‘gluteomorphine’ and ‘casomorphine’. These ‘peptides’ then bind
to ‘opiate receptors’ in the ‘central nervous system’ and to imitate the
effects of ‘opiate drugs’. During digestion, ‘opioid peptides’ are formed which
then led to an increased activity in the ‘endogenous opioid system’ and
resulted in the symptoms of autism. Hence, a diet low in gluten and casein is
believed to improve the cognitive-behavioural function of persons with ASD
(Lange,
Hauser, & Reissmann, 2015, n.p).

 

Children diagnosed with
autism tend to also suffer from comorbid problems which cause gastrointestinal
symptoms and affect their concentration and attention span. Past research
studies also associated gluten intolerance with ASD and indicated the
relationship between ASD and celiac disease, an autoimmune disease that causes gastrointestinal
syndrome (Lange, Hauser, & Reissmann, 2015; Jackson, Eaton, Cascella,
Fasano, & Kelly, 2012, pp 95-96).

 

Intervention’s
Definition of Improving Quality of Life

The purpose of choosing
a non-invasive intervention or therapy is to improve the quality of life for
the diseased. A Gluten Free Diet (GFD) tends to be the preferred intervention
used by parents of children with ASD because it is not a form of medication, non-evasive
in nature, as compared to other form of therapy, such as stem cell therapy. Currently,
GFD is widely used by individuals with celiac disease and by parents who have
children diagnosed with ASD to improve their children’s quality of life. However,
due to misinformation circulating online or by ill advice from unqualified
sources regarding the benefits or harmful effects of GFD, it is legitimate to
examine the accuracies or inaccuracies, the fact and fiction of using GFD, as a
form of intervention. With the growing popularity of parents putting their
children on a GFD, in the belief that it is a risk free intervention to relieve
their children’s autistic symptoms, it might pose important implications for
them (Reilly, 2016).

 

A
recent UK survey indicated that 80% of parents of children with
autism spectrum disorders tend to use some form of dietary intervention for
their child, out of which 29% of the parents placed their child on a gluten-free
and casein-free diet (GFCFD). On examining the effects of using GFCFD on their
children, 20–29% of the parents reported significant improvements on the
cognitive-behavioural function. The findings also suggested that a gluten-free
and casein-free diet did help to relieve comorbid problems such as gastrointestinal
symptoms, and improve the concentration, and attention span of these children. Although
parents in the studies gave positive effects of GFCFD on their children, most
scientific evaluations have failed to confirm its therapeutic effects. Using parents
as informants on their children’s autistic symptoms can be a bias source of
information. Perhaps, in future case studies, we need to include clinicians as informants
and assessors of the effects, to introduce standardized test procedures and observational
parameters. It will then complement the measures and give a more complete
picture of dietary effects of GFCFD on children with ASD (Lange, Hauser &
Reissmann, 2015).

 

The use of GFCFD by
parents on their children might have some loop holes that need to be addressed.
For example, some parents may go ahead to place their child on GFCFD without
testing their child for celiac disease or consulting a dietician. Some children
with celiac disease may be asymptomatic from the start and thus was not noticed
for having the condition. Furthermore, information on the health and social
consequences of starting a child on GFCFD are not adequate online or in books,
for parents to make an informed choice (Reilly, 2016).

 

Research
studies behind Intervention and Evaluations

According to Lange, et
al. (2015), GFCFD trials evaluating the effects of a GFCFD on autistic symptoms
have so far been questionable and inconclusive. The authors also mentioned that
research studies investigating the efficacy of a GFCFD in the treatment of
autism are seriously flawed and the therapeutic value of this diet appeared to
be weak and restricted. A systematic review of research papers published from
1970 to date also indicated that most research studies conducted on children
with ASD who are placed on a gluten-free diet were mostly tested on randomized
controlled trials and with a small sampling size. Hence, it lacks validity and reliability
and is unable to provide a sound scientific evidence to conclude the effectiveness
of adopting a gluten-free diet as a form of intervention.

Recent research studies
indicated that gluten sensitivity (GS) is an illness distinct from celiac
disease. This new discovery gave rise to new understanding and knowledge of the
disease. Both celiac disease and GS may present with a variety of neurologic
and psychiatric co-morbidities. However, for those with GS, the prime symptoms
are extra-intestinal problems. It was found that those with celiac disease have
villous atrophy or antibodies present in their bodies, unlike those with GS who
do not have the antibodies. Hence, GS if remained untreated, can lead to
psychiatric and neurologic manifestations in persons with ASD (Jackson, et al.,
2012).

 

Jackson, et al. (2012)
also cited a few research studies indicating an increased risk of ASDs in
children with a ‘maternal history of rheumatoid arthritis’, ‘celiac disease’
and ‘irritable bowel syndrome’. Another study used a control group to make
comparison. It was found that persons with ASDs and their family members have a
high percentage of people with ‘abnormal intestinal permeability’ as compared
to the group without ASDs. Another control group study of GFCFD used on patients
with ASD have found ‘a better intestinal permeability’ as compared to patients
on a non-GFCFD. As most of the research studies tend to focus on the use of
GFCFD rather than eliminating GFCFD on persons with ASDs, it makes it dif?cult
to determine whether there is additional bene?cial effects if a non-GFCFD is
used (p. 95).

 

The beneficial effects
of a GFCFD on autistic symptoms have so far been contradictory and remained
debatable to date and there is not enough data to support its benefits (Mari-Bauset,et
al.,2014; Gaesser & Angadi, 2012, p. 1330). In fact, recent evidence
suggested that a gluten-free diet might reduce beneficial gut bacteria in the
intestines. Other reports also indicated that patients who are obese tend to
put on even more weight after being placed on a gluten-free diet. It could be
due to better absorption of nutrients or healing of intestinal lining following a gluten-free diet (Gaesser
& Angadi, 2012). This might have an implication on obese children with ASD
to put on more weight if they were to use a gluten-free diet as a form of
intervention.

 

Reilly (2016) asserted
that there is not enough evidence to support the health benefits of a
gluten-free diet. On the contrary, a gluten-free diet may have negative effects
if it is not prescribed or approved by a registered dietician or physician.Gluten-free
packaged food also tend to have higher sugar and fat content as compared to
non-gluten-free food. Intake of too much sugar and fat may increase the risks
of obesity. There are emerging evidences to show that a strictly rice flour
gluten-free diet without other varieties of gluten-free products may lead to
toxicity due to ‘arsenic’,found in inorganic form in most rice-based gluten-free
products. A gluten-free diet may also result in deficiencies in vitamin B,
folate and iron. Hence, it is a myth to think that eating a gluten-free diet is
a healthier choice (Reilly, 2016, pp. 206-207).

 

A recent research study
was conducted by Hyman, Stewart, Foley, Cain, Peck, Morris, Wang, & Smith (2016),
on the safety and ef?cacy of the gluten-free/casein-free (GFCF) on a group of 14
children (age 3–5 years) with autism. They were put on GFCF diet for 4–6 weeks
and followed by placebo controlled challenge study for 12 weeks while
continuing the diet, with a 12-week follow-up. Children were given weekly
snacks that contained gluten, casein, gluten and casein, or placebo during the
dietary challenges with nutritional counselling. The findings indicated that the
GFCF diet was safe and well-tolerated. However, the limitation of this study
was that it was unable to track the signi?cant effects on physiologic
functioning, behaviour problems, or autism symptoms. Due to the small sampling
size, the ?ndings must be interpreted with caution and has to be replicated on
a larger scale to validate the findings.

 

The scienti?c community
has all along tried to establish alternative ways of intervention. To date,
there is no pharmacological treatment that is available to gluten-intolerant
patients. Placing patients on a strict, life-long gluten-free diet appeared to
be the only safe solution although it is still not conclusive regarding its
effectiveness. A research study was conducted by Caputo, Marilena, Stefania
& Esposito (2010) on the use of enzymes as additives or as processing aids
in the food biotechnology industry to detoxify gluten. The recent development
of ‘enzyme therapy’ is a new alternative intervention that focused on
inactivating immunogenic gluten epitopes and is administered orally to patients.
For people with ASD, it might spell new hope and be a new strategy to relieve
their autism symptoms and improve cognitive-behavioural functions. Persons
undergoing this therapy are administered doses of ‘Flavobacterium
meningosepticum’, ‘Sphingomonas capsulate’, and ‘Myxococcus xanthus’. These
enzymes are believed to help ‘degrading proline-containing peptides’ that are
otherwise resistant to degradation by ‘proteases’ in the gastrointestinal tract.
A lifelong gluten-free diet may not be easy to maintain and does cause a
negative impact on the quality of life. It is also a costly affair to stick to
a gluten-free
diet whereas a non-gluten-free diet is commonly available and cheaper to
maintain (Caputo, Marilena, Stefania & Esposito, 2010, pp.4-5; Zarkadas, et
al., 2013).

 

A systematic review of
the medical literature related to GFCFD was conducted by Mari-Bauset, et al. (2014).The
researchers tracked databases dating back from the 1970s to September, 2013 on
published research articles or written reports on the use of GFCFD on children
with ASD as an intervention. The systematic review evaluated the findings and
reported that none of the studies identified provided conclusive evidence of
GFCFD effectiveness as an intervention for ASD because they were poorly validated.
The
studies are mostly
tested on randomized controlled trials, with a small sample size thus cannot be
conclusive or represented.

 

A recent research study
conducted in 2008 by Zarkadas, et al.,(2013) investigated the effects of
gluten-free diet among Canadians with coeliac disease. A questionnaire was
mailed to all 1,0693 members of both the Canadian Celiac Association and the Fondation
québécoise de la maladie cœliaque. A total of 5912 (age?18 years)
responded which is equivalent to 72% of the response rate. The findings
reflected the difficulties encountered, the strategies used and the emotional
impact of following a gluten-free diet. For example, a significantly higher
percentage of women than men reported often feeling frustrated and isolated
during both time periods of treatment. As there is lack of research studies on
gender response in regards to GFCFD’s intervention on persons with ASD, it is
worth investigating this aspect.

 

Future
Directions and Conclusion

Past research studies
and evidences regarding the effectiveness of a GFCFD as an intervention therapy
for persons with autism are still inconclusive and lack robust evidences.
Despite the diet’s popularity and the positive feedbacks from parents regarding
its effects, most scientific evaluations have failed to confirm therapeutic
effects. Adhering to a GFCFD is highly complex, costly and impacts on all
activities involving food, making it difficult to maintain in the long term and
may be perceived as a negative impact on the quality of life. Cross-sectional
study of these nature are challenging to evaluate the emotional impact of
following a gluten-free diet and the difficulties faced by users or the effectiveness
of the strategies used (Lange et. al., 2015; Zarkadas, et al., 2013).

 

Perhaps in future
dietary studies, it should include longitudinal studies on single case or group
study. As a GFCFD can be costly, more research studies could be done to explore
potentially cheaper options and a more functional alternative. Other than rice,
corn, and potato starch products, the use of chestnut flour and flours
developed from fruit by-products, for example, OP and defatted strawberry seeds
could be explored (O’Shea, 2014). Apart from parents as informants
of the effectiveness of the GFCFD, clinical expert ratings should also be sought
and behavioural observations be gathered from various sources, to give a more complete
picture of the dietary effects of GFCFD on children with ASD.