New "atopic" clinical entities in search of pathogenesis and treatment
Review article
The Relationship of Autism and Gluten

https://doi.org/10.1016/j.clinthera.2013.04.011Get rights and content

Abstract

Background

Autism is now a common condition with a prevalence of 1 in 88 children. There is no known etiology. Speculation about possible treatments for autism or autism spectrum disorders (ASD) has included the use of various dietary interventions, including a gluten-free diet.

Objective

The goal of this article was to review the literature available evaluating the use of gluten-free diets in patients with autism to determine if diet should be instituted as a treatment.

Methods

A literature review was performed, identifying previously published studies in which a gluten-free diet was instituted as an autism treatment. These studies were not limited to randomized controlled trials because only 1 article was available that used a double-blind crossover design. Most publish reports were unblinded, observational studies.

Results

In the only double-blind, crossover study, no benefit of a gluten-free diet was identified. Several other studies did report benefit from gluten-free diet. Controlling for observer bias and what may have represented unrelated progress over time in these studies is not possible. There are many barriers to evaluating treatment benefits for patients with autism. Gluten sensitivity may present in a variety of ways, including gastrointestinal and neurologic symptoms. Although making a diagnosis of celiac disease is easier with new serology and genetic testing, a large number of gluten-sensitive patients do not have celiac disease. Testing to confirm non–celiac gluten sensitivity is not available.

Conclusions

A variety of symptoms may be present with gluten sensitivity. Currently, there is insufficient evidence to support instituting a gluten-free diet as a treatment for autism. There may be a subgroup of patients who might benefit from a gluten-free diet, but the symptom or testing profile of these candidates remains unclear.

Introduction

Autism and autism spectrum disorders (ASD), identified rarely in the past, are now increasing in prevalence. The most recent data reported by the Centers for Disease Control and Prevention found autism to be present in 1 in 88 children in the United States.1 This study reported that 1 in 54 boys and 1 in 252 girls are affected with autism.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,2 autism is characterized by: qualitative impairments in social interaction; qualitative impairments in communication; and restrictive, repetitive, and stereotyped patterns of behavior, interests and activity. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, scheduled for release in May 2013, collapses previously distinct autism subtypes, including autistic disorder and Asperger syndrome, into 1 unified diagnosis, autism spectrum disorders (ASD). In addition, the 3 current symptom domains of social impairment, communication deficits, and repetitive/restricted behaviors will be reduced to social communication impairment and repetitive/restricted behaviors.

Although there is no defining etiology for the presentation of the symptoms that constitute ASD, there is a clear promotion of the condition through a variety of genetic factors.3, 4 The condition is more frequent in families of affected children. The rising prevalence suggests that other factors are contributory, including: familial autoimmunity,5, 6 metabolic derangement,7 and possible epigenetic modification from environmental or dietary factors.8

Gastrointestinal (GI) problems are commonly described in children with autism; however, many of these problems are seen in the general pediatric population as well. A higher frequency of underlying GI pathology in children with autism has not been consistently identified in the published medical literature.9 In 1 study, Valicenti-McDermott et al10 reported that 70% of children with autism had GI problems compared with 42% of children with other neurodevelopmental problems such as cerebral palsy and 28% of children with typical development. In a database review that allowed assessment of medical history, Campbell et al11 reported that 43% of children with autism had GI problems compared with 4% of unaffected siblings whose data were also available.

Children with ASD have the added factor of communication impairment when it comes to presenting with medical conditions. They may not be able to explain when they are in pain and can present with problem behaviors as the manifestation of underlying illness.12

The goal of the current article was to review the literature available evaluating the use of gluten-free diets in patients with autism to determine if diet should be instituted as a treatment.

Section snippets

Methods

Published studies in which a gluten free diet was identified through a MEDLINE search limited to articles from 1990–2012, English language only, using search terms autism, autistic, gluten, casein, diet and nutrition inserted into the keywords field. These articles were obtained and reviewed for this paper, not all available papers are referenced.

Food and Autism

Speculation about gluten as a cause or contributor to autism or other neuropsychiatric conditions such as schizophrenia was proposed soon after the original description of autism by Leo Kanner.13 Scattered references appeared in the literature, suggesting a connection between nutritional factors and “neurobehavioral” symptoms. Prugh,14 Daynes,15 and Asperger and Belp16 suggested a link between behavioral disturbances and celiac disease (gluten sensitivity). Dohan et al17, 18 hypothesized a

Gluten Sensitivity Does Not Equal Celiac Disease

Part of the confusion regarding the issue of food causing symptoms may start with the nomenclature of intolerance. We understand celiac disease to be a specific immune response. We also recognize food allergy if it causes an anaphylactic event, and we know that there are other reactions to food that do not cause a serologic antibody response. This can be carbohydrate intolerance, in which individuals are unable to digest a dietary product, or sensitivity, which is typically considered to be an

Conclusions

As we look forward, we need to consider the heterogeneity of the autism population. It seems unlikely that any diet, supplement, medicine, or even educational modality may work for every individual. Whiteley et al41 suggests that part of our difficulty will be to determine proper measures and expectations for the time needed to assess a response. Especially for dietary interventions, identifying a subgroup with characteristic presentation may allow a better prediction of—and perhaps expectation

Conflicts of Interest

The author has indicated that he has no conflicts of interest regarding the content of this article.

Acknowledgements

Dr. Buie was responsible for the literature search, data interpretation, and writing of the manuscript.

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