Overweight and Obesity in Children with Autism Spectrum Disorder (ASD): a Critical Review Investigating the Etiology, Development, and Maintenance of this Relationship

Optimizing Learning Outcomes when Teaching Sight Words using Fruits and Vegetables as Reinforcers

Reinforcers frequently chosen may not offer the same nutritional value as fruits and vegetables. Prior researchers have explored preferences and the effectiveness of salty and sweet foods compared to fruits and vegetables, but the criteria for demonstrating effectiveness have often been arbitrary rather than academic. In addition, it remains unclear how the integration of these potentially nutritious reinforcers might affect learning or hinder learning efficiency. Therefore, the objective of this study was to investigate whether introducing fruits or vegetables as potential reinforcers could sustain responding achieved with salty or sweet reinforcers. The implications of this model for incorporating a variety of reinforcers while maintaining responding are also discussed.

Effectiveness of animal-assisted activities and therapies for autism spectrum disorder: a systematic review and meta-analysis

Background

Given the rising interest in complementary therapeutic strategies for autism spectrum disorder (ASD), this research aims to provide a comprehensive analysis of the impact of animal-assisted activities and therapies (AAAT) on various ASD symptoms.

Methods

A meticulous search of databases, including Scopus and PubMed, was conducted to gather relevant research on AAAT for ASD. This process led to the selection of 45 studies encompassing 1,212 participants. The chosen studies were then subjected to a meta-analysis to evaluate the efficacy of AAAT in alleviating core ASD symptoms.

Results

The meta-analysis revealed significant improvements in several core ASD symptoms due to AAAT. Notably, there were improvements in social communication (MD = -4.96, 95% CI [-7.49, -2.44]), irritability (MD = -2.38, 95% CI [-4.06, -0.71]), hyperactivity (MD = -4.03, 95% CI [-6.17, -1.89]), and different word usage skills (MD = 20.48, 95% CI [7.41, 33.55]). However, social awareness (MD = -1.63, 95% CI [-4.07, 0.81]), social cognition (MD = -3.60, 95% CI [-9.36, 2.17]), social mannerisms (MD = -0.73, 95% CI [-2.55, 1.09]), social motivation (MD = -1.21, 95% CI [-2.56, 0.13]), lethargy (MD = -1.12, 95% CI [-3.92, 1.68]), and stereotypical behaviors (MD = -0.23, 95% CI [-1.27, 0.80]) did not significantly improve.

Conclusion

The study demonstrates the potential of AAAT in improving certain core symptoms of ASD, such as social communication, irritability, hyperactivity, and word usage skills. However, the effectiveness of AAAT in other ASD symptom domains remains uncertain. The research is limited by the absence of long-term follow-up data and a high risk of bias in existing studies. Therefore, while the findings indicate the promise of AAAT in specific areas, caution is advised in generalizing its efficacy across all ASD symptoms.

Anthropometric Profile, Overweight/Obesity Prevalence, and Socioeconomic Impact in Moroccan Children Aged 6-12 Years Old with Autism Spectrum Disorder

BACKGROUND

In addition to the inherent challenges of their condition, children with autism spectrum disorder (ASD) are also susceptible to the global obesity epidemic. However, concerning the prevalence of obesity within the Moroccan ASD pediatric population, data remain scarce.

METHODS

A total of 258 children (boys = 195) aged 6 to 12 years old (mean = 9.4 ± 1.4) diagnosed with ASD participated in this study. Besides the body mass and height, four significant anthropometric markers for assessing obesity were examined: body mass index (BMI), body surface area (BSA), waist circumference (WC), and waist-to-height ratio (WHtR). Each anthropometric marker was categorized into one of three cardiometabolic risk levels based on the Z-scores and their corresponding percentiles. The distribution was as follows: low risk (≤84th percentile), high risk (85th-94th percentile), and very high risk (≥95th percentile). Subsequently, a multiple regression analysis was employed to develop an algorithm that generates a composite risk score. This score incorporates all the anthropometric variables simultaneously, while also weighting their individual contributions to the cardiometabolic risk.

RESULTS

Children with ASD exhibit an anthropometric profile that markedly increases their susceptibility to cardiometabolic issues. While roughly 11% of the general Moroccan child population is overweight or obese, this figure soars to nearly 60% among children with ASD when considering the central adiposity markers. Furthermore, children from middle-class socioeconomic backgrounds display a more than threefold greater risk of developing overweight or obesity compared to their counterparts from lower socioeconomic backgrounds.

CONCLUSIONS

This study has, for the first time, provided an up-to-date overview of the cardiometabolic risk in Moroccan children with ASD using traditional anthropometric measurements. The primary risk factor is clearly linked to central (abdominal) adiposity, which is recognized as the most deleterious. This study highlights the need to include general and central obesity markers. This study underscores the importance of incorporating both general and central adiposity markers for a more comprehensive assessment, and it emphasizes the need for closer monitoring within this high-risk population.

Piloting a Community-Based, Culturally Adapted Health Promotion Program for Children with Autism Spectrum Disorder and Developmental Disabilities in First-Generation Korean Immigrant Families

Children with autism spectrum disorder and developmental disabilities (ASD/DD) face barriers to participation in health promotion programs due to the lack of available and/or affordable programs and trained staff at recreation centers. Children with ASD/DD in Korean immigrant families are one of the most underserved minority groups due to language, racial/ethnic discrimination, and stigma and shame within their own ethnic community. However, little research is available on development, implementation, and evaluation of a culturally adapted community health promotion program in this population. The purpose of this study is to assess effectiveness of a pilot program for children with ASD/DD from first-generation Korean immigrant families. The pilot study used a quantitative, quasiexperimental design (one-group design with pre- and posttest) following a seven-week health promotion program. We recruited 15 children with ASD/DD, ages nine through 16, from first-generation Korean immigrant families. The findings of the study suggest that the pilot program was effective in gaining nutrition knowledge and increasing physical involvement among participants. Given the fact that Asian immigrants are a fast-growing population and that nearly 75 percent of them were born abroad, development and evaluation of a community-based, culturally adapted health promotion program is urgently needed.

Recommended practices for virtual nutrition education interventions for adolescents with autism spectrum disorder: A reflection from two pilot interventions during the COVID-19 pandemic

Youth with autism spectrum disorder (ASD) demonstrate unhealthy eating behaviors and dietary patterns compared to their neurotypical counterparts. Given the increased risk of unhealthy weight gain and the onset of the COVID-19 pandemic, modified nutrition programs in this population are warranted. The authors independently conducted two virtual pilot interventions during COVID-19 that offered feasible and acceptable alternatives to in-person delivery, providing unique opportunities for participant engagement and family involvement. Future virtual nutrition education programs for adolescents with ASD may include visual and verbal aids through Zoom, more parent/family integration, and accommodations for those with varying ASD severity levels.

Assessment Methods for Problematic Eating Behaviors in Children and Adolescents With Autism Spectrum Disorder

Autism spectrum disorder (ASD) can be associated with eating problems. However, currently, there is a lack of established guidelines for assessing and addressing eating behaviors in individuals with ASD. This gap in research exists due to the challenges associated with using traditional assessment methods, which may lead to discrepancies in responses and unintentional potential biases from caregivers. In this review, we provided a comprehensive overview of various eating behaviors commonly observed in individuals with ASD. These behaviors include 1) food neophobia, 2) selective eating, 3) binge eating, 4) food avoidance, 5) chewing and swallowing problems, 6) pica, 7) rumination, 8) rituals, and 9) problematic behaviors. Furthermore, we provide a perspective of utilizing digital tools: 1) augmentative and alternative communication; 2) ecological momentary assessment; and 3) video analysis, behavioral analysis, and facial expression analysis. This review explores existing assessment methods and suggests novel assessment aiding together.

Exploring the intersection of autism spectrum disorder and eating disorders: understanding the unique challenges and treatment considerations for autistic women with eating disorders

PURPOSE OF REVIEW

Autistic women struggle with high levels of both autistic eating behaviours and disordered eating behaviours , which might make them particularly vulnerable to develop eating disorders. Research investigating the presence and characteristics of eating disorders in autistic women is however limited, as is research examining the role of autism in the treatment and recovery of an eating disorder in autistic women.

RECENT FINDINGS

The link between autism and eating disorders has mainly been investigated from the field of eating disorder research, with studies finding an overrepresentation of autism or autistic traits in eating disorders populations. Findings also suggest that autism or autistic traits are associated with a more serious presentation of the eating disorders, including a higher chance of a chronic course of the eating disorders. Most studies however lack comprehensive autism assessments, making it difficult to determine the actual prevalence of autism and its role in women with eating disorders.

SUMMARY

Autistic women with an eating disorder seem to suffer from more complex eating disorders and seem to not benefit from current treatment modalities. This could be partly related to specific autism characteristics such as sensory sensitivities, which are not being considered by current treatment protocols. Future research needs to shed light on what underlies the eating behaviours of autistic women with an eating disorder, in order to help to adapt current treatment modalities to meet the unique needs of these women.

Health conditions in autism: Defining the trajectory from adolescence to early adulthood

Autistic adults, as compared to non-autistic adults, have increased rates of nearly all medical and psychiatric conditions. Many of these conditions begin in childhood, although few longitudinal studies have been conducted to examine prevalence rates of these conditions from adolescence into early adulthood. In this study, we analyze the longitudinal trajectory of health conditions in autistic youth, compared to age and sex-matched non-autistic youth, transitioning from adolescence into early adulthood in a large integrated health care delivery system. The percent and modeled prevalence of common medical and psychiatric conditions increased from age 14 to 22 years, with autistic youth having a higher prevalence of most conditions than non-autistic youth. The most prevalent conditions in autistic youth at all ages were obesity, neurological disorders, anxiety, and ADHD. The prevalence of obesity and dyslipidemia rose at a faster rate in autistic youth compared to non-autistic youth. By age 22, autistic females showed a higher prevalence of all medical and psychiatric conditions compared to autistic males. Our findings emphasize the importance of screening for medical and psychiatric conditions in autistic youth, coupled with health education targeted at this population, to mitigate the development of adverse health outcomes in autistic adults.

Is Bariatric Surgery an Option for Obesity in Autism Spectrum Disorder?: A Case Report

ABSTRACT

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication and interaction, stereotypical behaviors, and restricted interests or activities present during early periods of development. Obesity, which is an important public health problem, is also becoming a serious problem in individuals with ASD. In this case report, we aimed to represent the multidisciplinary medical and psychiatric treatment of a 16-year-old adolescent with ASD and obesity who was consulted for bariatric surgery.

Nutrient intake and adequacy in children with autism spectrum disorder: EPINED epidemiological study

LAY ABSTRACT

Children with autism spectrum disorder (ASD) have a fivefold elevated risk of developing eating problems, which predisposes them to nutritional deficiencies. This study assesses nutritional intake and adequacy in children with ASD, subdiagnostic autistic symptoms and typically developing (TD) children. Preschool children with ASD and subdiagnostic symptoms had slightly lower intake of monounsaturated fatty acids (MUFA), vitamin D and vitamin B12. Primary school children with ASD and subdiagnostic symptoms had slightly higher intake of protein, cholesterol, thiamine and niacin, and a higher percentage of obesity than children with TD. All children had a high intake in sugars, fats and saturated fatty acids; a very highly inadequate intake of vitamins (vitamins D and E), fibre, b-carotene, calcium and magnesium; and a moderately inadequate intake of vitamin C, folate and iron. However, although all children need nutrition advice, children with ASD and subdiagnostic autistic symptoms had a poorer quality diet than those with TD.

Physical Activity, Gut Microbiota, and Genetic Background for Children and Adolescents with Autism Spectrum Disorder

It is estimated that one in 100 children worldwide has been diagnosed with autism spectrum disorder (ASD). Children with ASD frequently suffer from gut dysbiosis and gastrointestinal issues, findings which possibly play a role in the pathogenesis and/or severity of their condition. Physical activity may have a positive effect on the composition of the intestinal microbiota of healthy adults. However, the effect of exercise both on the gastrointestinal problems and intestinal microbiota (and thus possibly on ASD) itself in affected children is unknown. In terms of understanding the physiopathology and manifestations of ASD, analysis of the gut-brain axis holds some promise. Here, we discuss the physiopathology of ASD in terms of genetics and microbiota composition, and how physical activity may be a promising non-pharmaceutical approach to improve ASD-related symptoms.

Toward automatic motivator selection for autism behavior intervention therapy

Children with autism spectrum disorder (ASD) usually show little interest in academic activities and may display disruptive behavior when presented with assignments. Research indicates that incorporating motivational variables during interventions results in improvements in behavior and academic performance. However, the impact of such motivational variables varies between children. In this paper, we aim to address the problem of selecting the right motivator for children with ASD using reinforcement learning by adapting to the most influential factors impacting the effectiveness of the contingent motivator used. We model the task of selecting a motivator as a Markov decision process problem. The states, actions and rewards design consider the factors that impact the effectiveness of a motivator based on applied behavior analysis as well as learners' individual preferences. We use a Q-learning algorithm to solve the modeled problem. Our proposed solution is then implemented as a mobile application developed for special education plans coordination. To evaluate the motivator selection feature, we conduct a study involving a group of teachers and therapists and assess how the added feature aids the participants in their decision-making process of selecting a motivator. Preliminary results indicated that the motivator selection feature improved the usability of the mobile app. Analysis of the algorithm performance showed promising results and indicated improvement of the recommendations over time.

Meeting the 24-h movement guidelines and health-related outcomes among youth with autism spectrum disorder: a seven-country observational study

BACKGROUND

Meeting daily guidelines for physical activity, screen time, and sleep duration is associated with a host of health indicators for youth. In this cross-sectional observational study, we investigated the associations between adherence to the movement guidelines and health-related outcomes among youth with autism spectrum disorder (ASD).

METHODS

Parents of youth with ASD (10-17 years) from seven countries and regions were invited to provide online proxy-reports for child's movement behaviors (i.e., physical activity, sleep and screen time), and health-related outcomes (i.e., body mass index [BMI], general health, and quality of life). A series of multiple linear regression analyses were used to examine the associations between meeting movement guidelines and health-related outcomes, adjusted for covariates.

RESULTS

The final sample consisted of 1165 youth with ASD. Compared with youth meeting all three guidelines, a higher BMI z-score was observed in those who met no guidelines (B = 0.62, P = 0.04), "sedentary time only" (B = 0.60, P = 0.047), and "physical activity plus sleep only" (B = 0.85, P = 0.04). Compared with meeting all three guidelines, meeting no guidelines was associated with poorer general health (B = - 0.46, P = 0.02). Further, compared with youth meeting all three guidelines, a lower quality of life score was observed in those who met no guidelines (B = - 0.47, P = 0.02) and "physical activity only" (B = - 0.62, P = 0.03). Lastly, there were dose-response associations between the number of guidelines met and all three health-related outcomes (all P_trend < 0.05).

CONCLUSIONS

In conclusion, meeting more 24-h movement guidelines was generally associated with more favorable health-related outcomes in youth with ASD. The low level of adherence to all three guidelines (2.0%) suggests the urgent need to promote the adoption of all the guidelines in this group.

The Food Environment Around Primary Schools in a Diverse Urban Area in the Netherlands: Linking Fast-Food Density and Proximity to Neighbourhood Disadvantage and Childhood Overweight Prevalence

In the Netherlands, the neighbourhood food environment has received little attention in initiatives to combat overweight/obesity. This study maps the food environment around primary schools in The Hague, The Netherlands, and examines associations between neighbourhood disadvantage, the school food environment and childhood overweight using Geographic Information Systems (GIS). Linear regression analyses were performed to test the association between schools' disadvantage scores (proxy for neighbourhood disadvantage) and relative fast-food density within 400 m and 1000 m and fast-food proximity. Univariable and multivariable linear regression analyses were used to test the association between the school food environment and overweight prevalence among children in the respective sub-district in which the schools is found. Multivariable analyses were adjusted for the schools' disadvantage scores. Results show that fast-food outlets were available around most primary schools. Schools in disadvantaged neighbourhoods were closer to and surrounded by a higher number of fast-food restaurants, grillrooms and kebab shops. On the sub-district level, the density of such fast-food outlets was associated with overweight prevalence among children. These findings highlight the importance of national and local policies to improve the food environment, particularly in disadvantaged neighbourhoods.

Comparison of Social Media Use Among Adolescents with Autism Spectrum Disorder and Non-ASD Adolescents

Background

It has been well documented that social media use among adolescents is rising. However, most research has focused on social media use among typically developing adolescents and less on its use among adolescents with autism spectrum disorder (ASD). The goal of this study was to compare the time spent as well as to identify the purpose of social media use in adolescents with ASD compared to non-ASD adolescents.

Methods

This was a cross-sectional study of adolescents between ages 13–18 who were attending a hospital-based child and adolescents psychiatry clinic. Participants completed a self-report 18-item questionnaire to assess the pattern and reasons for using social media sites. The sample size was 26 for ASD and 24 for the non-ASD group.

Results

We found that the time spent on social media among adolescents with ASD was comparable to those without ASD diagnosis. However, participants with ASD differed from their non-ASD counterparts in both preferred social media sites as well as reasons for use. The most favourable social media site for ASD adolescents was YouTube. In contrast, the preferred social media site among adolescents without ASD was Snapchat. About 92.3% of participants without ASD reported using social media sites for primarily social interactions. In contrast, 59.1% of participants with ASD reported entertainment purposes as their primary reason for choosing a social media site.

Conclusion

Although the current study is based on a small sample of participants, the findings suggest that the pattern of usage and reasons for using social media differ significantly between the two groups. There is, therefore, a definite need for further research with a larger sample size to examine the implications of these differences and to determine how social media could be used as a tool for learning social skills and its efficacy and safety in the ASD population.

Autism Spectrum Disorder and Obesity in Children: A Systematic Review and Meta-Analysis

INTRODUCTION

Children and adolescents with autism spectrum disorder (ASD) appear to be at greater risk of excess weight gain. The aim of this systematic review and meta-analysis was to examine whether children with ASD have a greater prevalence of obesity and whether the prevalence of ASD is higher in children with obesity.

METHODS

We conducted a systematic search on PubMed, Scopus, and PsychINFO until May 21, 2021. We used the meta package in the R in order to calculate the pooled prevalence and relative risk of obesity in children with ASD.

RESULTS

We found 20 eligible studies investigating the prevalence of obesity in children with ASD, with the prevalence ranging from 7.9 to 31.8% and from 1.4 to 23.6% among controls. All but three studies originated from the USA. The proportion of children with obesity in ASD populations was 17% (95% confidence interval [CI]: 13-22). The relative risk of obesity in children with ASD compared with control children was 1.58 (95% CI: 1.34-1.86). There were no controlled studies reporting on the prevalence of ASD in children with obesity.

CONCLUSION

Children and adolescents with ASD have a higher prevalence of obesity than healthy controls. There is a need for further prevalence studies of obesity in children with ASD, especially outside the USA, since the few European studies carried out have failed to show a significant difference between obesity prevalence in children with and without ASD. There is no knowledge at all regarding the prevalence of ASD among children with obesity.

Dietary Patterns and Weight Status in Italian Preschoolers with Autism Spectrum Disorder and Typically Developing Children

Atypical eating habits are more common in children with autism spectrum disorders (ASD) than typically developing (TD) peers. Feeding problems may lead to the double burden of specific nutrient deficiencies and excessive weight gain, with a consequent increase in obesity prevalence. The dietary intake of Italian preschoolers with ASD compared to their TD peers and the impact of their dietary choices on their weight status and relationship to food selectivity (FS) were investigated. Dietary patterns and their associations with body mass index (BMI) were evaluated in 65 children with ASD and 82 peers with TD aged 1.3-6.4 years. Eating habits were assessed with a modified version of a parent-rated semi-quantitative Food Frequency Questionnaire. Moreover, the prevalence of FS and possible links with dietary patterns and BMI were investigated in the ASD group. Children with ASD consumed significantly higher amounts of simple sugars, processed and ultra-processed carbohydrates, both low- and high-fat animal proteins, and lower amounts of vegetables and fruits compared to peers with TD. The obesity rate was 1.5% in children with TD and more than fourfold (6.2%) in children with ASD, although the difference between groups was not statistically significant. FS was significantly more frequent in children with ASD than in peers with TD. Children with ASD and FS showed significantly lower annual intakes of vegetable proteins and fiber (considered essential nutrients for a healthy diet) than children with ASD without FS. Our results showed that children with ASD showed different dietary habits than those with TD, with the higher consumption of energy-dense foods and lower amounts of food-sourced fibers, which could place them at increased risk to develop overweight, obesity, and micronutrient deficiencies later in life.

Parental Feeding Practices and Child-Related Factors are Associated with Overweight and Obesity in Children and Adolescents with Autism Spectrum Disorder

Atypical eating behaviors displayed by children with autism spectrum disorder (ASD) predispose them to unhealthy weight gain. We determined the factors associated with body weight status among 261 children with ASD (3-18 years) at nine autism intervention centers. Their mothers completed a self-administered questionnaire on sociodemographic background, parenting style, parental feeding practices, parenting stress, sleep habits, eating behaviors, and autism severity. Children with older age, non-full term gestational age, high maternal perceived weight, high maternal concern about child weight, and low pressure to eat were more likely to be overweight and obese. Obesity is a major concern among children with ASD. Healthy weight management programs for parents should incorporate appropriate feeding practices and a healthy perception of body weight.

Differences in Body Mass Index (BMI) in Early Adolescents with Autism Spectrum Disorder Compared to Youth with Typical Development

Adolescence is a time of exceptional physical health juxtaposed against significant psychosocial and weight-related problems. The study included 241, 10-to-13-year-old youth with autism spectrum disorder (ASD, N = 138) or typical development (TD, N = 103). Standardized exams measured pubertal development, height (HT), weight (WT), heart rate (HR), blood pressure (BP) and Body Mass Index (BMI). Analysis of Variance showed no significant between-group differences for HT, WT, HR, or BP (all p > 0.05). There was a significant difference in BMI-percentile between the groups (F(1,234) = 6.05, p = 0.01). Using hierarchical linear regression, significant predictors of BMI-percentile included diagnosis, pubertal stage and socioeconomic status. Pre-to-early pubescent children with ASD evidence higher BMI percentiles compared to youth with TD suggesting they may be at heightened risk for weight-related health concerns.

Children with Autism Spectrum Disorder Spent 30 Min Less Daily Time in Moderate-to-Vigorous Physical Activity than Typically Developing Peers: a Meta-Analysis of Cross-sectional Data

It remains unclear if participation in moderate-to-vigorous physical activity (MVPA) differs between children with ASD and typically developing children (TDC). We compared daily MVPA, time spent in MVPA during physical education (PE) and recess, and odds of not meeting MVPA recommendation (60 min/day) between children with ASD and TDC. Nine studies reporting accelerometer-measured MVPA were included in the meta-analyses. MVPA was 30 min lower/day, 12% and 8% lower during PE and recess, respectively, in children with ASD, and they had 4 times higher odds of not meeting MVPA recommendation when compared to TDC. Children with ASD engage in daily MVPA less than TDC and below the guidelines. Tailored interventions to increase MVPA in children with ASD are warranted.

Weight status and body composition analysis among Polish boys with autism spectrum disorders

Currently, autism spectrum disorders (ASD) are one of the main health care problems in both Poland and in other countries. There are limited studies on the physical growth and body composition among children and adolescents with ASD. Several studies have indicated that the prevalence of unhealthy weight is high among autistic patients. Therefore, the main aim of this study was to assess the prevalence of underweight, overweight and obesity of Polish boys with ASD and to analyse body composition.

A cross-sectional study was performed on 29 Polish boys aged 3–11 with autism. Anthropometric measurements were taken. Bioelectrical impedance analysis (BIA) was used to evaluate body composition. The percentile values and z-scores for body height, body weight and BMI were calculated. The CDC cut–points were used to determine weight status. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 25.

16.1% autistic boys had z-scores for body weight above two standard deviations, 12.9% had z-scores for body height above two standard deviations and z-scores for BMI above two standard deviations were found in 19.4% of the boys. 13.8% of autistic boys were underweight, 48.3% had healthy weight, 20.7% were overweight, and 17.2% were obese. The mean value of body fat percentage was 18.46%, and 16.1% of the boys with ASD had higher than normal fat tissue.

There is a high prevalence of overweight and obesity among Polish boys with autism.

The 24-Hour Movement Guidelines and Body Composition Among Youth Receiving Special Education Services in the United States

BACKGROUND

The purposes of this study were to examine the proportions of youth receiving special education services in the United States who individually and jointly met physical activity, screen time, and sleep duration guidelines, and to examine the impact of meeting none, one, two, and three of the guidelines on overweight and obesity.

METHODS

This cross-sectional analysis utilized data from the 2016 to 2017 National Survey for Children's Health data set on 3582 youth aged 10-17 years who received special education services. The frequency of the participants' compliance with the 24-hour movement guidelines and body weight status (based on the age- and sex-specific percentile cutoffs) were estimated. Meeting guidelines was defined as: 9-11 hours/night (5-13 y) or 8-10 hours/night (14-17 y) of sleep, ≤120 minutes per day of screen time, and ≥60 minutes per day of moderate to vigorous physical activity. A multinomial logistic regression analysis was conducted to estimate the impact of meeting none, one, two, or three guidelines on body weight status, adjusted for potential confounders.

RESULTS

Overall, 8.1% of youth met all three guidelines, 42.0% met two guidelines, 38.0% met one guideline, and 11.9% did not meet any guideline. Meeting all three guidelines was associated with an approximately 50% decreased likelihood of overweight than meeting no guideline, or sleep or screen time guidelines independently.

CONCLUSIONS

This study extends the 24-hour movement framework to children receiving special education services and should prompt the continued study of its utility for understanding health disparities experienced by this population.

An investigation of the diet, exercise, sleep, BMI, and health outcomes of autistic adults

BACKGROUND

Studies of autistic children suggest that restricted eating, reduced physical activity, and sleep disorders are common; however, no studies attempt to broadly describe the diet, exercise, and sleep patterns of autistic adults or consider relationships between lifestyle behaviors and the widely reported increased risks of obesity and chronic conditions. To address this, the authors developed the largest study of lifestyle patterns of autistic adults and assessed their relationships to body mass index, health outcomes, and family history.

METHODS

We administered an anonymized, online survey to n = 2386 adults (n = 1183 autistic) aged 16-90 years of age. We employed Fisher's exact tests and binomial logistic regression to describe diet, exercise, and sleep patterns; mediation of seizure disorders on sleep; body mass index (BMI); relationships of lifestyle factors to BMI, cardiovascular conditions, and diabetic conditions; and sex differences among autistic adults.

RESULTS

Autistic adults, and particularly autistic females, exhibit unhealthy diet, exercise, and sleep patterns; they are also more likely to be underweight or obese. Limited sleep duration and high rates of sleep disturbances cannot be accounted for by epilepsy or seizure disorders. Lifestyle factors are positively related to higher risk of cardiovascular conditions among autistic males, even more than family history.

LIMITATIONS

Our sample may not be representative of all autistic and non-autistic people, as it primarily comprised individuals who are white, female, have a high school education or higher, and reside in the UK. Our sampling methods may also exclude some individuals on the autism spectrum, and particularly those with moderate to severe intellectual disability. This is a cross-sectional sample that can test for relationships between factors (e.g., lifestyle factors and health outcomes) but cannot assess the direction of these relationships.

CONCLUSIONS

Autistic adults are less likely to meet minimal health recommendations for diet, exercise, and sleep-and these unhealthy behaviors may relate to excess risk of cardiovascular conditions. Although the present study can only provide preliminary, correlational evidence, our findings suggest that diet, exercise, and sleep should be considered and further investigated as key targets for reducing the now widely reported and dramatically increased risks of health comorbidity and premature death among autistic individuals compared to others. Physicians should work cooperatively with patients to provide health education and develop individualized strategies for how to better manage challenges with diet, exercise, and sleep.

Do Children with Autism Spectrum Disorders Eat Differently and Less Adequately than Those with Subclinical ASD and Typical Development? EPINED Epidemiological Study

Food consumption in children with ASD, subclinical ASD and with typical development (TD), and their adequacy to dietary recommendations was studied. A school population sample of 77 children with ASD, 40 with subclinical ASD, and 333 with TD participated. Compared to children with TD, pre-schoolers with ASD consumed fewer raw vegetables and less fish and eggs, while primary school children consumed fewer legumes, raw vegetables, citrus fruits, cheese/yogurt and olive oil, and more meat. All groups consumed an excess of sugar but those with ASD consumed even a greater amount than their peers. The higher prevalence of obesity found in primary school children with ASD may be the consequence of a less healthy eating pattern sustained over time.

Correlates of Feeding Difficulties Among Children with Autism Spectrum Disorder: A Systematic Review

Feeding difficulties related to selective intake, or eating a limited variety of foods, are very common in children with autism spectrum disorder (ASD). A systematic search of PubMed, Embase, PsycInfo, and CINAHL identified 29 studies that evaluated eight correlates: age, ASD symptoms and severity, cognitive and adaptive skills, sensory processing and perception, challenging behavior, weight status, gastrointestinal symptoms, and parenting stress. Feeding difficulties related to selective intake are consistently correlated with impaired sensory processing and perception and tend to be positively associated with rigidity and challenging behavior. These feeding difficulties tend to persist with advancing age. Other correlates demonstrated inconsistent findings. A significant limitation of research reviewed is variability in terminology, definitions, and measurement of feeding difficulties.

Altered patterns of brain dynamics linked with body mass index in youth with autism

Children with autism spectrum disorder (ASD) have higher rates of overweight and obesity (OWOB) compared with typically developing (TD) children. Brain functional connectivity differences have been shown in both ASD and OWOB. However, only one study to date has examined ASD and OWOB concurrently, so little is known regarding the neural mechanisms associated with the higher prevalence of OWOB and its behavioral impacts in ASD. We investigated co-activation patterns (CAPs) of brain regions identified by independent component analysis in 129 children and adolescents between 6 and 18 years of age (n = 68 ASD). We examined the interaction between body mass index (BMI) and diagnosis in predicting dynamic brain metrics (dwell time, DT; frequency of occurrence, and transitions between states) as well as dimensional brain-behavior relationships. The relationship between BMI and brain dynamics was moderated by diagnosis (ASD, TD), particularly among the frequency of CAP 4, characterized by co-activation of lateral frontoparietal, temporal, and frontal networks. This pattern was negatively associated with parent-reported inhibition skills. Children with ASD had shorter CAP 1, characterized by co-activation of the subcortical, temporal, sensorimotor, and frontal networks, and CAP 4 DTs compared with TD children. CAP 1 DT was negatively associated with cognitive flexibility, inhibition, social functioning, and BMI. Cognitive flexibility moderated the relationship between BMI and brain dynamics in the visual network. Our findings provide novel evidence of neural mechanisms associated with OWOB in children with ASD. Further, poorer cognitive flexibility may result in increased vulnerability for children with ASD and co-occurring OWOB. LAY SUMMARY: Obesity is a societal epidemic and is common in autism, however, little is known about the neural mechanisms associated with the higher rates of obesity in autism. Here, we find unique patterns of brain dynamics associated with obesity in autism that were not observed in typically developing children. Further, the relationship between body mass index and brain dynamics depended on cognitive flexibility. These findings suggest that individuals with autism may be more vulnerable to the effects of obesity on brain function. Autism Res 2021, 14: 873-886. © 2021 International Society for Autism Research, Wiley Periodicals LLC.

Global prevalence of obesity, overweight and underweight in children, adolescents and adults with autism spectrum disorder, attention-deficit hyperactivity disorder: A systematic review and meta-analysis

Individuals with autism spectrum disorder (ASD) or attention-deficit hyperactivity disorder (ADHD) may have unhealthy bodyweight. This meta-analysis was performed to understand the weight status in individuals with ASD or ADHD. PubMed, Embase, Cochrane and ISI Web of Science databases were searched from inception until June 2020 to identify relevant studies. Prevalence estimates and their 95% confidence intervals (CIs) of obesity, overweight and underweight were separately pooled using random-effects models. A total of 95 studies were included in the meta-analysis. The pooled estimates of the prevalence of obesity, overweight and underweight were 21.8%, 19.8% and 6.4% in individuals with ASD and 14.7%, 20.9% and 4.0% in individuals with ADHD. In subgroup analyses, an increasing trend in the prevalence of unhealthy weight was observed from children aged 2 to 5 years to adults with ASD (obesity: from 16.7% to 31.3%, overweight: from 16.2% to 27.2%, underweight from 5.3% to 8.6%) and from children aged 6 to 12 years to adults with ADHD (obesity: from 13.5% to 19.3%, overweight: from 18.8% to 31.2%). The worrisome epidemic of obesity and overweight in individuals with ASD, ADHD highlighted the need for weight management.

Gastrointestinal Symptoms and Feeding Problems and Their Associations with Dietary Interventions, Food Supplement Use, and Behavioral Characteristics in a Sample of Children and Adolescents with Autism Spectrum Disorders

Autism spectrum disorders (ASD) are characterized by impairments in social interaction, communication, and restricted, stereotyped behavior. Gastrointestinal (GI), nutritional, and feeding problems are often reported in ASD. We investigated the prevalence of GI symptoms, food selectivity, and mealtime difficulties, and their associations with dietary interventions, food supplement use, and behavioral characteristics in a sample involving 247 participants with ASD and 267 controls aged 2-18 years. Data were collected by a questionnaire. GI symptoms were observed in 88.9% of children and adolescents with ASD, more often in girls than in boys. High rates of food selectivity (69.1%) and mealtime problems (64.3%) were found. Food supplements were used by 66.7% of individuals, mainly vitamins/minerals, probiotics, and omega-3 fatty acids. In the ASD sample, 21.2% of subjects followed a diet, mostly based on gluten and milk restriction, including individuals exhibiting food selectivity. Frequency of GI symptoms, food selectivity, and mealtime problems correlated weakly, but significantly with behavioral characteristics in the ASD group, but not with food supplement use. The study demonstrated that higher frequency of GI symptoms, food selectivity, and mealtime problems are a common problem in pre-schoolers, schoolchildren, and adolescents with ASD, and together with dietary modification, they are significantly associated with ASD.

Impact of Psychoactive Drug Use on Developing Obesity among Children and Adolescents with Autism Spectrum Diagnosis: A Nested Case-Control Study

BACKGROUND

Obesity in children on the autism spectrum (AS) is becoming a significant health concern. The purpose of this study was to identify the predictors of obesity in a cohort of AS youth and to assess the impact of psychoactive medication use while exploring the second-generation antipsychotics (SGAs) dose-response curve.

STUDY DESIGN

A nested case-control study was conducted using Quebec public administrative databases. Subjects with AS <18 years [≥2 diagnoses International Classification of Diseases: 9th revision (ICD-9): 299.X] were identified (January 1993 to May 2011). Cases were defined as subjects with an obesity diagnosis (ICD-9: 278.X) during the coverage period and matched to 10 controls for age, gender, and follow-up duration. Potential risk factors for obesity (sociodemographic characteristics, other neuropsychiatric conditions, and psychoactive drug use) were evaluated and analyzed using conditional logistic regression.

RESULTS

From a cohort of 5369 AS subjects, we identified 135 obesity cases. Among the different risk factors, only SGAs [rate ratio (RR): 1.04, 95% confidence interval (CI): 1.01-1.07] increased the probability of obesity in multivariate analysis. Exposure for ≥12 months increased significantly the likelihood of obesity (RR: 2.01, 95% CI: 1.18-3.42). Higher risk was observed with chlorpromazine-equivalent daily doses ≥100 mg (RR: 2.20, 95% CI: 1.00-4.84). Among SGA users, concomitant antidepressants (per 30-day exposure) slightly increased the probability (RR: 1.08, 95% CI: 1.01-1.15).

CONCLUSIONS

Longer and higher SGA exposure increased the risk of obesity, which has to be considered in relation to the paucity of evidence supporting long-term psychoactive medication use in AS children. Results highlight the need to promote optimal use and interventions to mitigate metabolic side effects of SGAs in this population.

Putting positive weight-related conversations into practice: The pilot implementation of a Knowledge Translation Casebook

BACKGROUND

Healthcare professionals (HCPs) play an important role in discussing weight with children and their parents but report barriers such as lack of training and supports. These barriers are especially prevalent within specialized populations such as children with autism spectrum disorder (ASD). To address this, a Knowledge Translation Casebook on positive weight-related conversations was developed by a research team at a Canadian paediatric hospital. The purpose of the current pre-implementation pilot study was to explore initial acceptability and adoption of the Casebook into clinical settings.

METHODS

An interactive, multimodal education workshop was created to provide HCPs with knowledge and training on how to have positive weight-related conversations with children and parents. Two workshops were conducted using the same curriculum but delivered either in-person or online. Participants were drawn from a team of clinicians at a teaching hospital whose care focuses on medication management for clients with ASD and clinicians participating in a distance learning programme on best practice care for clients with ASD. Participants completed a demographic questionnaire, workshop evaluation, and a pre-workshop and post-workshop questionnaire. Descriptive statistics were used to summarize demographic, questionnaire, and survey data. Answers to open-ended questions were analysed using content analysis.

RESULTS

Participants agreed that the workshop gave them a clear understanding of the Casebook's content and helped them easily navigate the Casebook. Based on raw scores, self-efficacy in having weight-related conversations seemed to increase from pre-to post-workshop, but reported weight-management clinical practice scores did not change over time. However, the small sample precluded in-depth statistical analysis.

CONCLUSIONS

The Casebook was acceptable and appeared to increase self-efficacy about having weight-related conversations with children with ASD and parents. More robust implementation strategies are needed to foster the uptake of best practices in weight-related conversations into clinical practice.

Prevalence of overweight among youth with chronic conditions in the United States: An update from the 2016 National Survey of Children's Health

BACKGROUND

Surveillance of overweight trends among youth with chronic conditions can inform the prioritization of funding, research and intervention.

OBJECTIVES

The primary objective of this study was to utilize the 2016 National Survey of Children's Health (NSCH) data to provide current estimates of the prevalence of overweight among US youth with common chronic conditions. A secondary purpose was to examine parental concern about weight status among youth with chronic conditions who were overweight.

METHODS

This study included children aged 10 to 17 years with (n=10 997) and without (n=13 408) chronic conditions from the 2016 NSCH. Estimates of overweight, and parental concern for weight status, were compared among youth with 19 common chronic conditions and youth without chronic conditions.

RESULTS

Overall, youth with chronic conditions were significantly more likely to be overweight compared with youth without chronic conditions (35.4% vs 27.8%). Overweight was most prevalent among youth with diabetes (56.4%), intellectual disabilities (53.6%) and hearing impairments (46.1%). Parents of youth with chronic conditions who were overweight were significantly more concerned that their child's weight was too high than those without chronic conditions.

CONCLUSIONS

This study identifies youth with chronic conditions, particularly those with certain conditions, as being in need of prioritization of funding, research and intervention.

A Pilot Study Investigating the Feasibility and Acceptability of a Parent-Only Behavioral Weight-Loss Treatment for Children with Autism Spectrum Disorder

Evidence-based weight-loss treatments for children with autism spectrum disorder (ASD) are lacking. Therefore, a parent-based weight-loss treatment for children with ASD (PBT-ASD) was developed. A pilot study was conducted to test the initial efficacy, feasibility, and acceptability of this intervention. Parents of 20 children with ASD and overweight/obesity (mean age = 9.90 (SD = 2.31) years; 90% male; 40% Hispanic) participated in a 16-session PBT-ASD. The PBT-ASD program was found to be feasible and acceptable. Both children and parents lost weight from pre- to post-treatment (p's < .05). Parent-reported child physical activity and vegetable consumption increased at post-treatment (p's < .05). This pilot study provides a proof-of-concept for PBT-ASD. Randomized controlled trials with larger samples and follow-up are needed.

The risk of overweight and obesity in children with autism spectrum disorders: A systematic review and meta-analysis

Multiple studies have suggested that autism spectrum disorders seem to increase the risk of overweight and obesity. We examined the pooled prevalence and relative risk of developing overweight or obesity among children with autism spectrum disorders in a systematic review and meta-analysis. We searched PubMed, Scopus, ProQuest, and Web of Science databases and subsequently screened the records to identify studies that reported prevalence of overweight and/or obesity in children with ASD and matched groups of neurotypical children. DerSimonian-Laird random-effects meta-analyses were performed to examine pooled prevalence and relative risk of obesity in children with autism spectrum disorders using the "meta" package in R software. Among children with autism spectrum disorders, the prevalence of obesity was 22.2%. Children with ASD had a 41.1% greater risk (P = .018) of development of obesity. Non-Caucasian race, increasing age, female sex, and living in the United States emerged as positive moderators of the association between autism spectrum disorders and prevalence of overweight or obesity. Autism spectrum disorders seem to increase the risk of childhood obesity. Increased awareness of this association may allow the implementation of early interventions to reduce obesity and prevent potential deterioration of quality-of-life in this population.

The sex-specific association between autistic traits and eating behavior in childhood: An exploratory study in the general population

Children with Autism Spectrum Disorder (ASD) often exhibit problematic eating behaviors, an observation mostly based on male dominated, clinical ASD study samples. It is, however, important to evaluate both children with an ASD diagnosis and children with subclinical autistic traits as both often experience difficulties. Moreover, considering the suggestion of a possible girl-specific ASD phenotype, there is a need to determine whether autistic traits are related with problematic eating behaviors in girls as well. This study explores the sex-specific association between autism (both autistic traits and diagnosed ASD) and eating behavior in middle childhood in Generation R, a prospective population-based cohort from fetal life onwards. We collected parental reports of autistic traits at six years (Social Responsiveness Scale) and of eating behavior at ten years (Children's Eating Behaviour Questionnaire). In this cohort of 3559 children, autistic traits at six years were associated with more Picky Eating, Emotional Eating and Food Responsiveness in later childhood (e.g. adjusted B for Picky Eating = 0.07; 95% CI: 0.03, 0.11). Stratified analyses showed that in girls, autistic traits were associated with more Emotional Overeating and Emotional Undereating (e.g. adjusted B for Emotional Undereating = 0.12; 95% CI: 0.04, 0.20), while no associations were found for boys. Results comparing children with and without an ASD diagnosis in the cohort largely confirm these associations (e.g. in girls, adjusted B for Emotional Undereating = 0.72; 95% CI: 0.01, 1.42). Our results point to a sex-specific association between autism and eating behavior in middle childhood. Also, our study is the first study to show that autistic traits are associated with emotionally based eating problems in girls and possibly represent part of a girl-specific ASD phenotype.

Eating as an autistic adult: An exploratory qualitative study

Background

Although eating difficulties are known to be common in children on the autism spectrum, there is a lack of research on whether these behaviours persist or change into adulthood. Emerging evidence suggests that autistic adults may experience higher levels of disordered eating than the general population, indicating the impact of autism on eating in this adult population warrants further exploration.

Method

This study interviewed 12 autistic adults about their eating habits, with a focus on the continuing or changing presence of behaviours often seen in autistic children such as sensory sensitivity or a preference for routines. Interviews were transcribed and analysed using thematic analysis.

Results

Overall, participants suggested that autism did continue to impact their eating into adulthood, particularly in the areas of sensory sensitivity, medical difficulties, executive functioning difficulties, and rigidity, but that they had learned to adapt so that these issues no longer represented a problem. However, a minority of participants did feel that their autism had a negative effect on their eating, particularly those diagnosed with eating disorders. Additionally, eating behaviours associated with autism were identified as potentially contributing to having an unhealthy body weight.

Conclusions

Certain traits associated with autism, such as cognitive rigidity and sensory sensitivity, could potentially continue to influence the eating behaviours of autistic adults. These traits are typically experienced as differences which can be adapted around and managed, rather than specific problems. However, these traits can potentially contribute to difficulties such as disordered eating and weight gain, and the implications of these should be explored by future research.

Prevalence of overweight and obesity among US youth with autism spectrum disorder

The purpose of this study was to examine current overweight and obesity prevalence rates among US youth (aged 10–17 years) with and without autism spectrum disorder, based on the 2016 National Survey of Children’s Health. Analyses of weight status, derived from parent-reported height and weight measures, were conducted for a weighted sample of 875,963 youth with autism spectrum disorder and 31,913,657 typically developing youth. Controlling for age, race/ethnicity, income, and sex, youth with autism spectrum disorder had significantly higher odds of overweight (odds ratio = 1.48, p = 0.04) and obesity (odds ratio = 1.49, p = 0.02) compared to typically developing youth. Among youth with autism spectrum disorder, 19.4% were overweight and 23.05% were obese. Among typically developing youth, 14.9% were overweight and 15.91% were obese. Higher odds of obesity were reported for youth with severe autism spectrum disorder (odds ratio = 3.35, p < 0.01), compared to those with mild autism spectrum disorder.

A Review of Childhood Behavioral Problems and Disorders in the Development of Obesity: Attention Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and Beyond

PURPOSE OF REVIEW

Given the high rates of pediatric and adult obesity, it is imperative to identify early risk factors that might contribute to excess weight gain. This review aims to investigate the relationship between childhood behavioral problems with the development and persistence of obesity. Specifically, this review highlights the association of obesity with (1) neurocognitive constructs, such as executive functioning and inhibition/impulsivity, and (2) disorders commonly diagnosed in childhood, including attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).

RECENT FINDINGS

Consistent evidence supports a relationship between childhood behavioral problems, executive functioning, inhibition/impulsivity, ADHD, and ASD with obesity across the lifespan. Longitudinal studies suggest behavior problems, neurocognitive functioning deficits, and ADHD symptoms in childhood predict weight gain over time. Identifying risk factors in childhood that promote obesity may help develop targeted intervention and prevention programs. Additional research should elucidate mechanisms that account for these relationships.