A gluten- & casein-free diet as

an intervention for autism

spectrum disorder (ASD).

Paul Whiteley, Research Fellow

Autism Research Unit
Department of Pharmacy, Health & Wellbeing
Faculty of Applied Sciences, University of Sunderland, UK http://osiris.sunderland.ac.uk/autism
 Aims of presentation

The diet / health relationship.

Dietary interventions for ASD.
Gluten & casein-free diets.
Evidence currently available.
ScanBrit trial.
Potential mode(s) of action.
 Caveats

Much of the research in this presentation remains

under investigation.

Based on peer-reviewed research articles

(published or in press) not grey literature.

Dietary intervention should be viewed as

complimentary to other approaches for ASD.

Consultation with your childs physician is advised

before embarking on any dietary change.
 Interventions for ASD
Any intervention for ASD needs to bear in mind four very important factors
that will affect outcome:

(1) ASD (or PDD) is Pervasive.

Spread throughout, all encompassing.

(2) ASD is Heterogeneous.

Not uniform in structure or composition.

(3) ASD is often accompanied by co-morbidities.

e.g. epilepsy, ADHD, anxiety-related problems

(4) People with ASD differentially develop without specific intervention.

Age & environment may play a role
Diet & health are linked:
not just another
casual relationship!
 Diet & health relationship
Examples of a relationship between diet & health:

Physical health
Obesity & malnutrition significantly increased risk of developing several
physical symptoms & health-related diseases (including death).

Cognitive-mental health
PKU (Phenylketonuria) a leading causes of learning disability
prior to the discovery of Imbecillitas Phenylpyruvica. (Flling,1934)

Physical & cognitive-mental health

Coeliac (see-lee-ak) disease reaction to gluten protein causing
GI malabsorption, failure to thrive & linked to increased risk of
psychiatric co-morbidity (see later). (Aretaeus the Cappadocean, 200AD; Gee, 1887)
Diet & ADHD: acknowledgement of a relationship

Schonwald A. (2008) AAP Grand Rounds 19: 17

Could diet also
affect ASDs?
 Q: How many types of dietary intervention are
being used as an intervention for ASD?

A: Numerous !
Including (individually or combinations of):
Gluten / casein-free diets (Cereal and mammalian dairy produce)
MSG / aspartame free diets (Flavour enhancer/artificial sweetener)
Lutein-free diet (Carotenoid from fruit / vegetables)
Feingold diet (Artificial flavourings / colourings)
SCD (Complex carbohydrates / starches / processed sugars)

Combined with various dietary supplements (-3 oils, vitamins).

Q: How much evidence is there to support the use
of these dietary interventions in ASD?

A: It depends on who you talk to!

* Parents / primary caregivers

* Health / education / social care professionals
* Researchers
* Media
* Government

(All with varying degrees of persuasiveness!)

Autism Research Institute Feb 2008

 Q: How much scientific evidence is there to
support the use of dietary intervention in ASD?

A: Some, of varying degrees of objectivity

e.g. Ketogenic diet and autism (fat protein, carb)

N=30 children (4-10 years old)

60% of children showed improvement (varying degrees) on CARS.

Evangeliou A. et al (2003) Application of a ketogenic diet in children with autistic behaviour: pilot study.
Journal of Child Neurology 18: 113-118
 Q: Which dietary intervention for ASD
has been studied the most?

A: Gluten and casein-free diets

As of 2001:
11 Group studies
2 Surveys
3 Case reports
+ multiple anecdotal reports
Several other studies have been added to the list since.
Knivsberg A-M. et al (2001) Reports on Dietary Intervention in Autistic Disorders. Nutritional Neuroscience 4: 25-37
 Gluten & casein
What is gluten ?
A mixture of two proteins, gliadin & glutenin that give
flour a cohesive, elastic property to turn into dough.
Present in: wheat, barley & rye (oats <20% avenin).

What is casein ?
Primary protein found in mammalian dairy sources.
Several variants according to order / species*.
Present in: milk, cheese & yogurts.

* Kaminski S. et al (2007) Polymorphism of bovine beta-casein and its potential effect on human health.
Journal of Applied Genetics 48: 189-198
History of gf-cf diets in psychiatry

Schizophrenia & psychotic disorders.

Improvement in psychiatric symptoms on diet.

Dohan FC. et al (1973) Relapsed schizophrenics: earlier discharge from the hospital after cereal-free, milk-free diet.
American Journal of Psychiatry 130: 685-688.

Vlissides DN. et al (1986). A double-blind gluten-free/gluten-load controlled trial in a secure ward population.
British Journal of Psychiatry 148: 447-452

Extrapolation to autism & related ASDs.

Several trials suggestive of amelioration of symptoms.

 Dietary intervention studies
Knivsberg A-M. et al (1990) Dietary intervention in autistic syndromes. Brain Dysfunction 3: 315-327

Effect of both a gluten- & casein-free diet (n=15; 6-22 years)

Open trial (non-blinded / non-randomised).
Improvements reported in several areas:
Social interaction
Language use / comprehension
Sensory / motor abilities
[Reduction in peptide-like urinary material]

Participants followed-up after 4 years improvements continued.

 Dietary intervention studies
Lucarelli S. et al (1995) Food allergy and infantile autism, Panminerva Medica 37: 137-141

Effect of casein-free diet (alone)

(n=36; age 8-13 yrs) + control group (n=20)

Blind casein-challenge (placebo vs. casein capsules).

Significant changes (improvement) after 8 weeks of diet (BSE).

(e.g. isolation, verbal communication, cognition)

Detrimental changes to scores following dietary challenge.

 Dietary intervention studies
Whiteley P. et al (1999) A gluten free diet as an intervention for autism. Autism 3: 45-65

Effect of a gluten-free diet (alone) (n=22; mean age 4 years).

Open trial (non-blinded / non-randomised) + control groups.

Significant changes (improvement) after 5 months of diet (BSE):

motor (p=0.04) & eating disturbances (p=0.01), attention (p=0.02)

Improvement on 3 out of 6 cognitive subtests.

Changes to levels of urinary IAcrGly.

 Behavioural effects [1]

From the research trials conducted so far, the

behavioural effects of dietary intervention include:

Attention & concentration

Communication & language
Social integration
Motor co-ordination
Self-injurious behaviours But
 Behavioural effects [2]

Some indications of significant changes in group

results although not universally successful.

More detailed analysis of individual results suggested

that the younger, more severely affected children
were best responders.

Parents tended to be more pleased with the results

than teachers.
 Transient negative effects
Withdrawal phase is common at the early stages of
dietary intervention.

Variable & more apparent in younger children.

* Anxiety & clinginess

* Crying & general whinginess
* Staring into space
* Dizziness / decrease in movement
* Increased frequency of urination / defecation
* Flu type symptoms (adults)
 Breaking the diets

Transient but sometimes extreme reactions to the

ingestion of even small amounts of gluten / casein.

e.g. Increased hyperactivity

Spacing out
Increased aggression

Abatement of reactions following re-adoption of the

dietary intervention.
 Somatic symptoms in ASD

Evidence for the existence of somatic features co-morbid

to ASD diagnostic features.

Preliminary reports of improvement in somatic symptoms

following dietary intervention.

Whiteley P. et al (1998) Clinical features associated with autism: observations of symptoms outside the diagnostic boundaries of
autism spectrum disorders. Autism: 2: 415-422

Whiteley P. (2004) Developmental, behavioural and somatic factors in pervasive developmental disorders: preliminary analysis.
Child: Care, Health & Development 30: 5-11
 Abnormal bowel habits / conditions

One quarter of children with ASD have at least one

chronic gastrointestinal (GI) symptom.
Molloy CA. et al (2003) Prevalence of chronic gastrointestinal symptoms in children with autism and autistic spectrum disorders.
Autism. 7:165-171

Consumption of milk is a strong predictor of constipation.

Afzal N. et al (2003) Constipation with acquired megarectum in children with autism. Pediatrics 112: 939-942

Significant in mucosal eosinophil* infiltrate on gluten

and casein-free diet.
* white blood cell responsible for combating infection & controlling mechanisms involved in allergy

Ashwood P. et al (2003) Intestinal lymphocyte populations in children with regressive autism: evidence for extensive mucosal
immunopathology. Journal of Clinical Immunology 23: 504-517
 Nutritional status on diet

Not a widely researched area but:

No significant differences in energy, protein & nutrient intake

whilst on a gluten- & casein-free diet.
Cornish E. (2002) Gluten and casein free diets in autism: a study of the effects on food choice and nutrition.
Journal of Human Nutrition & Dietetics. 15: 261-269

Stewart PA. et al (2008) Nutritional quality of the gluten-free and casein-free diet. IMFAR poster proceedings

Trend towards levels of plasma tryptophan & tyrosine

( tryptophan has been found in non-dietary participants).
Arnold GL. et al (2003) Plasma amino acids profiles in children with autism: potential risk of nutritional
deficiencies. JADD 39: 449-454
 Bone thickness & calcium
Hediger et al (2008) Reduced bone cortical thickness in boys with autism or ASD. JADD

Bones were growing longer but not thicker than normal.

Possible explanations:
Use of casein-free diet ( calcium & vitamin D intake).
Lack of variety in food habits*.
GI issues affecting absorption of vitamins / minerals.
* Stewart C. Latif A. (2008) Symptomatic nutritional rickets in a teenager with autistic spectrum disorder.
Child: Care, Health & Development 34: 276-278

Requires further research on actual bone density (not thickness).

Reiterates the need for involvement of dietetic support.
The British Dietetic Association
Effective Practice Bulletin
Issue 37 November 2003
 Methodological issues

Issues yet to be addressed:

Open-trials not controlled trials.

Confirmation of diagnosis (ADI-R, ADOS-G).
Clarity on why the diet/s are working.
Recommendations of the Cochrane Review report
(2004) & MRC report on autism research (2001).

Millward C. et al (2004; 2008) Gluten and casein-free diets for autistic spectrum disorder. CD003498
 Double-blind study
Elder et al (2006) The gluten-free, casein-free diet In autism: results of a preliminary double blind clinical trial. JADD

Effect of a gluten-free /casein-free diet (n=15; age 2-6 yrs).

Double-blind cross-over trial.

12 week study (6 weeks on diet / 6 weeks off).

No significant changes to scores or peptide levels but

some reports of improvements on diet (real / placebo?).

Author criticism: Low study power / not long enough on diet?

 ScanBrit dietary study
Effect of a gluten-free & casein-free diet (n=72; age 4-11 yrs).
(ClinicalTrials.gov ID: NCT00614198)

Single-blind, randomised-controlled, matched-pair trial.

Comprehensive assessments (SCQ, ADOS, VABS, GARS, ADHD-IV)

Additional measures (dietary habits, somatic symptoms, urine

profiles, anthropometric data, quality of life).

Adaptive design with interim analysis based on pre-defined

thresholds of positive improvement (A: 24 months, B: 12 months).
 Why might these diets
work for people with ASD?
 The role of classical allergy?
Classical allergy response by the immune system.

Production of antibodies called Immunoglobulins (Ig-) to

an allergen (inflammatory response).

Various isotypes / classes of Ig- (IgA, IgE, IgG, IgM).

IgE (Type-1 hypersensitivity) = classical allergy.

Some indication of possible allergy to milk in ASD. (Lucarelli et al, 1996)

Contradictory evidence from skin prick tests. (Bakkaloglu et al, 2008)

Male D. et al (1996) Immunology (7th Edition). Mosby. (Prof. J. Brostoff as co-author)
Lucarelli S. et al (1995) Food allergy and infantile autism, Panminerva Medica 37: 137-141
Bakkaloglu B. et al (2008) Atopic features in early childhood autism. European Journal of Paediatric Neurology
 Lessons from coeliac disease?
Autoimmune-type GI disease genes & environment.
Most prevalent in the West of Ireland (potato famine ca.1845).
Familial risk factor (approx. 4.5% prevalence amongst 1 relatives)
Can be clinically silent (no serious overt symptoms).

Various somatic symptoms (present or not present) including:

Functional bowel habit problems
Fatigue / muscle wasting
Dyspepsia (pain / discomfort in upper GI tract)
Malabsorption
Anaemia (Fe or folate)*

Walker-Smith J. & Murch S. (1999) Diseases of the small intestine in childhood (4 th edition). Isis Medical Media.
 Lessons from coeliac disease?
Interesting parallels in somatic symptoms but:
Co-morbidity of CD & ASD = rare?? (no routine screening!).
People with CD do not necessarily present with autism.

Untreated CD is however associated with the appearance of various

behavioural / psychological symptoms including:
Depression (Ciacci et al, 1998)
Disruptive behaviours (Pynnnen et al, 2004)
Anxiety (Addolorato et al, 2001)
Learning disorders (Zelnik et al, 2004)
Schizophrenia (De Santis et al, 1997)
 A role for opiates?
Opioids class of natural & synthetic compounds
that bind to opioid receptors found in the CNS
and gastrointestinal tract (agonists).

Morphine is an exogenously derived opiate.

Endorphins & enkephalins are endogenous opiates.

Opioid peptides (chains of amino-acids) formed as a

consequence of the digestion of proteins.
e.g. gluten (cereal produce) gluten exorphins

Zioudrou C. et al (1979) Opioid peptides derived from food proteins: the exorphins. Journal of Biological Chemistry 254: 2446-49
Terenius L. et al (1986) Opioid peptides in the cerebrospinal fluid of psychiatric patients. Progress in Brain Research 65: 207-219
Teschemacher H, Koch G. (1991) Opioids in the milk. Endocrine Regulations 25: 147-150
Fukudome S. et al (1997) Release of opioid peptides, gluten exorphins by the action of pancreatic elastase. FEBS 412: 475-479
 Opiate effects overlap with ASD
Psychological
desire for social contact & diminished clinging behaviour.
[opioids inhibit the release of oxytocin the social hormone]
stereotypic behaviours (effects of apomorphine).
Impaired developmental, behavioural & organisational abilities.

Somatic
Altered EEG patterns.
tolerance to pain (analgesia).
Functional bowel habit problems (e.g. constipation).
Physiological / psychological effects following withdrawal.
Urca G. et al (1977) Morphine and enkephalin: analgesic and epileptic properties. Science 4298: 83-86
Kalat JW. (1978) Speculations on similarities between autism and opiate addiction. JACS 8: 477-479
Panksepp, J. (1979) A neurochemical theory of autism. Trends in Neurosciences 2: 174-177
Mihatsch WA. et al (2005) Hydrolysis of casein accelerates gastrointestinal transit via reduction of opioid receptor agonists
released from casein in rats. Biology of the Neonate 87: 160-163
Martindale: The complete drug reference (2007) Pharmaceutical Press
Opiate-related findings in ASD

levels of endorphin fragments in CSF samples.

Gillberg C. et al (1985) Endorphin activity in childhood psychosis. Spinal fluid levels in 24 cases.
Archives of General Psychiatry 42: 780-783

in plasma samples and family members - broader phenotype?

Leboyer M. et al (1999) Whole blood serotonin and plasma beta-endorphin in autistic probands and their first-degree
relatives. Biological Psychiatry 45: 158-163

in blood of neonates who went on to develop ASD*.

* Still under investigation following replication of these findings (Nelson et al, 2006)

Nelson K. et al (2001) Neuropeptides and neurotrophins in neonatal blood of children with autism or mental retardation.
Annals of Neurology 49: 597-606

Clinical use of opioid antagonists (e.g. Naloxone / Naltrexone)**.

** Low dose naltrexone (LDN) also potentially effective for the treatment of inflammatory bowel disease (Crohns disease)

Elchaar GM. et al (2006) Efficacy and safety of naltrexone use in pediatric patients with autistic disorder.
Annals of Pharmacotherapy 40: 1086-1095
 Autism as a metabolic disorder?
Body Brain Mind Behaviour
GI tract & brain derived from the same embryonic tissue.

Initial indications of GI permeability (40%).

Walker-Smith J, Andrews J. (1972) Alpha-1-antitrypsin, autism & coeliac disease. Lancet 7782: 883-884
DEufemia P. et al (1995) Abnormal intestinal permeability in children with autism. Acta Paediatrica 85:1076-1079

transport of peptides (& other material) across to the CNS.

Gardner ML. (1988) Gastrointestinal absorption of intact proteins. Annual Review of Nutrition 8: 329-350

Indications of abnormal GI conditions (bacteria, enzymes, etc).

Finegold SM. et al (2002) Gastrointestinal microflora studies in late-onset autism. Clinical Infectious Diseases 35: S6-S16
Parracho H. et al (2005) Differences between the gut microflora of children with autistic spectrum disorders and that of
healthy children. Journal of Medical Microbiology 54: 987-991

Amelioration of some symptoms by physical therapy.

Shattock P, Whiteley P. (2002) Biochemical aspects in autism spectrum disorders: updating the opioid-excess theory and
presenting new opportunities for biomedical intervention. Expert Opinion on Therapeutic Targets 6:175-183
 Conclusions
Exclusion diets may be helpful in ameliorating some of the
core and/or secondary symptoms of PDD for some people.

Balancing a constraining intervention with quality of life.

Further data/research required on long-term safety.

Theoretical basis to the diets is still under investigation although

may include a GI element.

Requirement for clinical support when using diets.

Evidence for the use of diet as good as most other interventions

(specialised education/behavioural plans).
Acknowledgments:
ScanBrit partners:
Dr. Demetrious Haracopos 1
Prof. Ann-Mari Knivsberg 2
Dr. Kalle (Tiny) Reichelt 3
Dr. Judith Jacobsen 4
Dr. Anders Seim
Dr. Lennart Pedersen 1
Paul Shattock 5
Sarah Parlar-Lorentzen 1
Maja Schondel 1
Maureen Pilvang 1
Jonna Deibjerg 1
Charlotte Mathiesen 1
Prof. Stefan Samuelsson 6
Partner affiliations:
1 The Center for Autisme, Herlev, Denmark
2 National Centre for Reading Education & Research, University of Stavanger
3 Faculty of Medicine, University of Oslo
4 Statcon ApS
5 Faculty of Applied Sciences, University of Sunderland
6 Department of Behavioural Sciences, Linkping University
Thanks also to our study funders:
The Center for Autisme
The Nils O. Seim Family Fund for Medical Research
The Eric Birger Christensen Fond
The Norwegian Protein Intolerance Association
The Robert Luff Foundation
A huge thank you to a very important group:
The families and children who participated in the study.
 The final word on not knowing:

As we know, there are known knowns. There are

things we know we know.
We also know there are known unknowns. That is to say
we know there are some things we do not know. But
there are also unknown unknowns, the ones we don't
know we don't know"

Donald Rumsfeld, February 12th 2002

Paul Whiteley, Research Fellow

Autism Research Unit
Department of Pharmacy, Health & Wellbeing
Faculty of Applied Sciences, University of Sunderland, UK
http://osiris.sunderland.ac.uk/autism