Autism is a complex developmental and non-curable neurobiological condition that typically appears during the first three years of life. (Christensen et al., 2016). Although the onset of symptoms for most children occurs during late infancy some may not display any symptoms until they are of 2 years after a period of comparative growth. It effects brain function predominantly in the areas of social interaction and communication skills that results in varying degrees of difficult socialization, verbal and nonverbal communications, repetitive and problematic behavior. The challenging manners of these children disrupt the food choices which in turn affect nutritional status and growth. Irritabilities and anxiety can be associated with introduction of new food.(K. Barnhill et al., 2017). Autism is prevalent worldwide with male are effected almost five times more than female.(Salih,et.al,2017). In Honk Kong 1 in 27 and in Norway 1 in 196, whereas in Pakistan 1 in every 50 children can be autistic. There are approximately 350,000 autistic children in Pakistan however, the actual number remains hidden due to underreporting, misdiagnosis and social causes. Regular nutritional screening and evaluation of Autistic children is an important clinical deliberation as they may have numerous risk factors that seem to intensify the occurrence of nutrient insufficiencies.

2. DIETARY PATTERNS OF AUTISTIC CHILDREN
Dr Saira Bano
Roll No BL 810439
Department of Environmental Design, Health and Nutritional Sciences
Allama Iqbal Open University H/8 Islamabad
Supervisor
Dr Hajra Ahmad
Chairperson /Associate Professor
Faculty of Science, Department of ED, H&N Sciences , AIOU Islamabad.

3. INTRODUCTION
Autism is a complex developmental and non-curable neurobiological condition that
typically appears during the first three years of life. (Christensen et al., 2016).
Although the onset of symptoms for most children occurs during late infancy some
may not display any symptoms until they are of 2 years after a period of comparative
growth.
It effects brain function predominantly in the areas of social interaction and
communication skills that results in varying degrees of difficult socialization, verbal
and nonverbal communications, repetitive and problematic behavior.
The challenging manners of these children disrupt the food choices which in turn
affect nutritional status and growth. Irritabilities and anxiety can be associated with
introduction of new food.(K. Barnhill et al., 2017).
Autism is prevalent worldwide with male are effected almost five times more
than female.(Salih,et.al,2017). In Honk Kong 1 in 27 and in Norway 1 in 196, whereas
in Pakistan 1 in every 50 children can be autistic. There are approximately 350,000
autistic children in Pakistan however, the actual number remains hidden due to
underreporting, misdiagnosis and social causes.
Regular nutritional screening and evaluation of Autistic children is an important
clinical deliberation as they may have numerous risk factors that seem to intensify the
occurrence of nutrient insufficiencies.

4. RATIONALE OF STUDY
 The nutritional requirements of children with special needs are
more than anyone else and any negligence or inattention can lead to
severe consequence of growth and development delay.
The maintenance of mental and social wellbeing is part and
parcel of various management concerns of autistic children.
Exploration of dietary association may lead to a better lifestyle for
autistic children.
The study about the dietary pattern and its effect on the daily
routine of autistic children has not been done before in Pakistan.
Dietary pattern and its usefulness has not been evaluated which could
have facilitated both children with autism and their parents.
Although there are some studies related to assessment of
relationship between food group consumption and physical wellbeing.
But association with mental and social wellbeing has not been
explored.
The research of dietary pattern and its relation to social and mental
functioning in early and later childhood of autistic individuals is
distinctive due to absence of any previous study.
This study will open new avenues and will help to touch
unexplored issues both at individual and community level.

5. STATEMENT OF PROBLEM
The behavioral features of autistic children are very peculiar and their
presence or severity may disturb the daily routine of these children and their
families.
Eating habits and patterns of Autistic children are often unfamiliar
and have a bearing on family life especially provision of nutritious diet. They
display specific acceptance of food, significant eating difficulties and limited
range of food selections. (Hudson,et.al,2017).
Autistic children frequently demonstrate nutrition linked therapeutic
issues comprising food sensitivities, gastrointestinal uneasiness and
inflammation, diarrhea, constipation and acid reflux.
Nutritional assessment of autistic children is not done in routine
which may lead to nutritional deficiencies.
The assessment of meal pattern helps us to identify their eating
preferences and behavioral features gives true depiction of their social and
mental aspects. Finding relationship between diet and social and mental will
benefit not only children but also their families.

6. SIGNIFICANCE OF STUDY
 Autism is a condition not easy to diagnose and even after diagnosis, the
task of treating and managing the condition poses an uphill task. Condition
is permanent and requires highly professional approach towards handling
of affairs.
 Number of autistic children in Pakistan is increasing but various aspects of
their nutritional needs are untouched. Ranging from improved health
benefits, to improving motor skills and overall functionality, staying active
makes a difference in these children’s lives.
 Different age groups involved in the study helped us to know about
various challenges encountered at different stages. Several social and
emotional variables were observed that have not been investigated in this
manner. Their challenging lifestyle and problems faced by parents are the
focus of this study.
 The information obtained will help parents, health professionals, therapists
and caregivers to focus more on those social and mental features which are
more prevalent in these children to lessen their efforts in providing them
with their various therapies.

7. OBJECTIVE
 To study dietary patterns of Autistic children.
 To evaluate the association of dietary patterns with social
and mental wellbeing of Autistic children.
NULL HYPOTHESIS: (Ho)
Dietary patterns has no effect on social and mental wellbeing of
Autistic children.
ALTERNATE HYPOTHESIS: (H1)
Dietary patterns has effect on social and mental wellbeing of
Autistic children.

8. METHODOLOGY
The methods and procedures followed were in accordance with the ethical guidelines
and standards. This study was approved by Board of advance study Allama Iqbal
Open University Islamabad.
Consents: Consent was taken from the from parents and directors of the resource
centers where autistic children are enrolled.
Study design: This was a cross sectional, analytical design, institutional based study.
Study population and Locale: It was applied to measure the dietary pattern of 110
autistic children aged between 3 years and 12 years enrolled in:
 Autism resource center Rawalpindi.
 Autism resource center Islamabad.
 Special children school E / 8 Islamabad.
Sampling Technique: Samples were drawn through purposive sampling technique.
The participants sought for this study were mothers / parents of children as the autistic
children are unable to give verbal information.
Inclusion criteria
Autistic children (both male and female) 3 to 12 years of age without any physical and
neurological disorder.
Exclusion criteria
Autistic children 3 to 12 years of age who have any physical disability and other
neurological disorders like cerebral palsy and seizures.

9. Sample size calculation:
The total sample size in this study was calculated keeping in view following facts:
-
a. Significance level or power of the study was 5%.
b. Confidence/probability level was 95%
c. The incidence of the condition is 0.07%.
d. The formula for such cross sectional studies as described:
n= [{Z × (1-α/2)} 2 × p × (1-P)]/d2.
e. In this study p was ≤ 0.05.
g. At this level Z (1-α/2) =1.96.
So the tentative sample size calculated was =
{(1.96)2 × (0.05) × (0.07)}/ (0.05)2 =70
To make the study more significant 110 children with autism were selected.
Dependent variables:
 Social and mental features of Autistic children.
Independent variables
 Dietary patterns of Autistic children.

10. REDSEARCH TOOLS;
The techniques and tools used for this study were:
1 . Questionnaire
Questionnaire was especially designed depending on the
variables, (104 Qs)
Variables were selected for collecting the following information.
i. Socio demographic data: name, age, gender, address, income
etc.
ii. Life style pattern: Physical activity and sleep pattern.
iii. Social and mental wellbeing scale (30Qs)
iv. Meal patterns: Breakfast, Lunch, dinner and snack times.
v. Food Frequency Questionnaire (FFQ): six food groups.
A total of 34 food and drinks were included and number of times
daily, weekly, monthly and never was marked.
2. Anthropometric examination.
i Height (m) and weight (kg)
ii BMI Formula: weight (kg)
[height (m)]2

11. DATA COLLECTION
 Data collection procedures took place from September 2018 till November 2018.
 The data collection involved visits to centers, taking consents, questionnaire
administration and collection of questionnaires after completion.
 After completing questionnaire at home by the parents, it was returned to
administrators of the resource centers and collected by researcher.
 One on one interview of mothers attending the centers was also done and
questionnaire was completed.
 The assessment of anthropometric measurements was done.
Coding and characterization.
After collecting the data, it was assembled, and responses were entered to software
IBM SPSS (Statistical Package for Social Sciences) Version 20 and responses recoded
to make it more compact and comprehensive.
Statistical analysis:
 Descriptive statistics like Frequencies, Means etc. were calculated.
 Pearson ` s Chi square ( ᵡ ²) analysis was used to find out the relationship between
dietary pattern, social and mental features. The p value was set at ≤0.05.

12. Limitation
i. The study may show under representation of
females and other age groups.
ii. Children of the families who participated in this
study were attending or enrolled in the centers and it is
possible that they had hesitations and apprehensions
about privacy of their child`s feeding pattern and
especially behavior characteristics.
Delimitation:
i. This study was confined to specific region
(Rawalpindi and Islamabad) and specific population.
ii. Only height and weight measurements were taken just
to reduce any apprehensions of parents, regarding any
disturbance to routine of autistic children.

13. Population
(n=110)
Age of children Gender of children Address of children
≤ 5
(3 to 5years)
≥ 6
(6 to 12years )
Male Female Islamabad Rawalpindi
Frequency 52 (47.3%) 58 (52.7%) 93 (84.5%) 17 (15.5%) 39 (35.5%) 71 (64.5%)
Education level of parents
≤Higher secondary ≤ Post graduate Professional skilled studies
Father 4.5% 77.3% 18.2%
Mother 13.6% 82.7% 3.6%
The frequency percentage of education and occupation of parents of Autistic
children.
PRESENTATION AND ANALYSIS OF DATA
Descriptive statistics
The frequency and percentage of age, gender, and address of Autistic children

14. The frequency of height , weight and BMI of Autistic children

15. Meal times Daily 2-4 times/week Never Mean ±S.E.
Breakfast 68.2% 18.2% 13.6% 1.45±.06
Morning snacks 60.9% 24.5% 14.5% 1.53±.07
Lunch 79.1% 17.3% 3.6% 1.24±.04
Evening snacks 56.4% 37.3% 6.4% 1.50±.05
Dinner 78.6% 20.9% 0.9% 1.22±.04
Bed-time meals 58.2% 21.8% 20.0% 1.61±.07
The frequency and mean of meal pattern of Autistic children.

16. Age of Children Breakfast Morning
snacks
Lunch Evening
snacks
Dinner Bed-time
meals
≤ 5 years
Education
of mother
.521 .604 .066 .963 .419 .418
Occupation
of mother
.103 .159 .566 .121 .109 .521
≥ 6 years
Education
of mother
.632 .590 .949 .621 .298 .448
Occupation
of mother
.945 .621 .004** .170 .000** .006**
The association of age and meal pattern of Autistic children.
Age of child Breakfast Morning
snacks
Lunch Evening
snacks
Dinner Bedtime
meals
≤ 5 years(n=52) .801 .181 .068 .727 .148 .417
≥6 years(n=54) .872 .141 .414 .280 .082 .118
The association of meal pattern of Autistic children and education and
occupation of mothers.

17. Food type Daily 1-4 times/week monthly Never
Mutton 10.9% 32.7% 48.2% 8.2%
Beef 11.8% 28.2% 49.1% 10.9%
Chicken 30.9% 39.1% 22.7% 7.3%
Fish 3.6% 6.4% 62.7% 27.3%
Lentils 13.6% 35.5% 32.7% 18.2%
Egg 47.3% 23.6% 26.4% 2.7%
FOOD GROUP CONSUMPTION
The frequency of meat, poultry and lentils intake by Autistic
children.

18. Food type Daily 1-4 times/week Monthly Never
Seasonal fruits 40.0% 37.3% 19.1% 3.6%
Seasonal vegetables 12.7% 50.0% 11.8% 25.5%
Potatoes 32.7% 51.8% 15.5% 15.5%
The frequency of vegetables and fruits intake by Autistic children.
Sugar y Foods Daily 1-4times week Monthly
Mithai 3.6% 23.6% 54.5%
Cake/pastry 10.9% 36.4% 40.0%
Biscuits 31.8% 46.4% 18.2%
Desserts 8.2% 20% 57.3%
The frequency of Sugary Foods intake by Autistic children

19. Food type
(Grains)
Daily 1-4times /week Monthly Never
Chapati 74.5% 13.6% 10.0% 1.8%
Paratha 55.5% 18.2% 19.1% 7.3%
Rice 21.8% 40.0% 30.9% 7.3%
Bread 50.9% 16.4% 17.3% 15.5%
Cereal 6.4% 20.0% 30.0% 43.6%
Dairy products Daily 1-4times week Monthly Never
Milk 76.4% 10.9% 7.3% 5.5%
Yogurt 12.7% 18.2% 50.9% 18.2%
Ice cream 9.1% 26.4% 40.9% 23.6%
Cream 0% 9.1% 33.6% 57.3%
Cheese 2.7% 6.4% 37.3% 53.6%
The frequency of Dairy products intake by Autistic children.
The frequency of Grains intake by Autistic children.

20. Junk food (solids) Daily 1-4times/week Monthly Never
Packed chips 25.5% 26.4% 49% 7.3%
French fries 38.2% 34.5% 24.5% 2.7%
Candies 27.3% 23.6% 32.7% 16.4%
Chocolate 22.7% 23.6% 38.2% 14.5%
Mayonnaise 0.9% 6.4% 37.3% 55.5%
Pizza 0% 10.9% 53.6% 35.5%
Rolls 0% 10.9% 56.4% 32.7%
Burgers 0% 0.9% 3.6% 95.5%
Samosa 0% 0% 6.4% 93.6%
Table 11 The frequency of intake of Junk foods(solids) by Autistic children.

21. Junk drinks Daily 1-4times /week Monthly Never
Packed juice 17.3% 34.5% 32.7% 15.5%
Fresh juice .9% 20.0% 50.9% 28.2%
Fizzy drinks 2.7% 29.1% 33.6% 34.5%
Tea 21.8% 8.2% 36.4% 33.6%
coffee 0% 3.6% 6.4% 90.0%
The frequency of intake of Junk drinks.

22. Mental wellbeing
features
Rarely Often Always Mean ±S. E
Depressed mood 36.4% 41.8% 21.8% 1.85±.071
Learning new skills 12.7% 48.2% 39.1% 2.26±.06
Aggression to self 32.7% 47.3% 20% 1.87±.06
Hyperactivity Frequency 7.3% 40.9% 31.8% 2.05±.073
Short attention span 9.1% 58.2% 32.7% 2.23±.05
Changes in mood 24.5% 37.3% 38.2% 2.10±.07
Repetitive movements 32.7% 39.1% 28.2% 1.95±.075
Fear of loud sound 39.1% 30.0% 30.9% 1.91±.079
Need same routine 28.2% 40.9% 30.9% 2.02±.073
Fearful feeling 39.1% 42.7% 18.2% 1.79±.069
The frequency and mean of behavioral (mental wellbeing) features

23. playing
with self,
65%
playing
with
others
35%
playing with
self
playing with
others
Types and duration of physical activity
<30min
42%
30-
60mins,
51%
> 60
mins,
7% <30mins
30-60mins
> 60 mins
regular
78%
Not regular
22%
Pattern Of Sleep
regular
Not regular
The frequency of behavioral features (mental wellbeing) of Autistic children

24. Yes, 50%
No, 50%
Sensitivity to loud sound
yes
no
none, 61%
Moving
objects,
23%
Noise ,
16%
Any other sensitivity
none
moving
objects
noise
Yes, 56%
No, 44%
Avoidance of distraction
yes
no
The frequency of behavioral features (mental wellbeing) of Autistic children

25. Social wellbeing features Rarely Often Always Mean±SE
Demonstrates dislikes 5.5% 50.0% 44.5% 2.39±.056
Communication with others 46.4% 33.6% 20.0% 1.74±.074
Avoidance of eye contact 23.6% 54.5% 21.8% 1.98±.065
Enjoyment of Social gatherings 19.1% 51.8% 29.1% 2.13±.076
Aggression to others 32.7% 48.2% 19.1% 1.86±.067
Comfort level to surroundings 7.3% 35.5% 57.3% 2.50±.060
Attention to others 10.9% 41.8% 47.3% 2.36±.064
Table 17 The frequency, mean of behavioral features (social wellbeing) of
Autistic children

26. Mental features Meat, Poultry
and lentils
Sugary
food
Fruits and
vegetables
Grains Dairy
products
Junk
solids
Junk
drink
Hyperactivity
Frequency
.004** .107* .142* .546* .235* .009** .078*
Repetitive movements .868* .278* .471* .223* .168* .133* .074*
Depressed mood .035** .200* .004** .443* .087* .010** .311*
Learning new skills .254* .397* .299* .353* .907* .873* .667*
Short attention span .522* .334* .013** .233* .069* .499* .074*
Changes in mood .584* .341* .136* .176* .151* .239* .002**
Aggression to self .022** .620* .609* .025** .235* .653* .004**
Association, (chi square Asymp.Sig.2-sided) between mental wellbeing features and food
group consumption by Autistic children.

27. Mental features Meat,
Poultry and
Lentils
Sugary
foods
Fruits and
vegetables
Grains Dairy
products
Junk
solids
Junk
drink
Physical activity Type .494* .754* .007** .014** .015** .542* .489*
Physical activity
Duration
.029** .319* .156* .066* .252* .756* .877*
Sleep Pattern .460* .640* .002* .047** .382* .040** .493*
Sleep Duration .012** .277* .318* .008** .082* .494* .280*
Distraction Avoidance .133* .027** .051* .047** .105* .190* .493*
Loud sound sensitivity .820* .794* .512* .184* .219* .464* .409*
Any other sensitivity .044** .079* .738* .001** .423* .783* .176*
Need the same routine .445* .764* .330* .038** .077* .100* .328*
Fearful feelings .118* .098* .008** .034** .292* .091* .001**
Table 20 Association, (chi square Asymp.Sig.2-sided) between mental
wellbeing features and food group consumption.

28. Social Features Meat, Poultry
and lentils
Sugary foods Fruits and
vegetables
Grains Dairy
products
Junk food
(solids)
Junk drink
Demonstrates
dislikes
.720* .208* .401* .570* .299* .106* .419*
Communication
with others
.138* .398* .009** .004** .002** .737* .259*
Eye contact
avoidance
.247* .481* .062* .002** .079* .853* .018**
Social gatherings
Enjoyment
.092* .419* .033** .815* .610* .132* .240*
Aggression
to others
.284* .517* .737* .027** .154* .854* .002**
Comfort level to
surroundings
.102* .032** .177* .470* .206* .801* .572*
Attention to others .327* .010** .150* .041** .300* .289* .133*
Association, (chi square Asymp.Sig.2-sided) between social wellbeing features and
food group consumption by Autistic children.

29. Social features Meat,
Poultry and
lentils
Sugary
food
Fruits and
vegetables
Grains Dairy
products
Junk solids Junk drink
New food refusal .112 .601 .149 .064 .106 .791 .127
Food Texture sensitivity .229 .002** 048** .195 .002** .516 .010**
Toy texture sensitivity .240 .000** .016** .079 .002** .128 .066
Smell sensitivity level .347 .577 .532 .104 .217 .725 .024**
Fear of loud sound .023** .049** .073 .382 .051 .005** .030**
Favorite food in same
utensil
.184 .429 .051 .225 .094 .363 .003**
Favorite food in same
environment
.049** .151 .012** .067 .095 .082 .006**
Favorite food in same
room
.026** .283 .546 .201 .635 .363 .000**
Association, (chi square Asymp.Sig.2-sided) between social wellbeing
features and food group consumption buy Autistic children

30. Food groups Asymp. Sig. (2-sided)
Behavioral
features
Meat,
Poultry and
lentils
Sugary
foods
Grains Dairy
products
Fruits and
vegetable
Junk
foods
Junk drinks
Mental wellbeing .001** .000** .412* .000** .100* .004** .016**
Social wellbeing .028** .103* .259* .158* .082* .294* .002**
Chi-Square Test
Dietary pattern and wellbeing Value D f Asymp. Sig.
(2-sided)
Pearson Chi-Square 1340.137a 1 .057
Likelihood Ratio 489.815 1 1.000
Linear-by-Linear Association 3.147 1 .076
N of Valid Cases 110
Association of mental and social wellbeing with food groups
consumption by Autistic children
Association of dietary pattern with wellbeing of Autistic children

31.  The sample consisted of 110 children with autism. The study shows the
preponderance of male children more than female children. The parents of the
children with autism mostly belonged to affluent, highly educated class.
 The majority of children were taking their lunch and dinner daily; very few
missed their regular meals.
 The dietary pattern study showed the rational meal pattern and diversity in food
consumption (healthy and junk foods) in children with autism. The behavioral
characteristics of these children are peculiar and manifested frequently.
 Statistically significant values were found between mental wellbeing
characteristics and protein, sugary foods, dairy products junk foods, junk
drinks. Whereas statistically significant values were found between social
wellbeing characteristics and meat and poultry and junk drinks. The association
was found between few food groups and behavioral features at individual level,
but cumulative association was not established as p value calculated in the
study was (p=.057) which is ≥.0.5.
 The individual food group consumption and subsequent manifestation of any
specific behavioral feature is found to be associated. Although the hypothesis
tested is not supporting that dietary pattern has direct effect on mental and
social wellbeing of children with autism yet their association at advance and in
depth level may be helpful for future researches.
CONCLUSIONS

32. RECOMMENDATIONS
 Autism in Pakistan has not received sufficient attention from
policy makers. This is a major hindrance in improving health
and wellbeing of children with autism. It is crucial to
ascertain the knowledge gaps which exist and take corrective
actions.
 Analysis of more female and older children would have
revealed more information. The age group studied expanded
to adult individuals also have significant impact for future
researches.
 Due attention should be paid to the consumption of healthy
food and behavioral features should be closely monitored to
reduce the burden both on parents and caregivers.
 Growth record and biochemical analysis should be
maintained regularly which will help to follow the pattern of
growth and further consultation with physicians in case of
any growth delayfor micro or macronutrient deficiencies is
found.