Autism Spectrum Disorder: Effectiveness of GFCF Diet Interventions

This report critically analyzes the Gluten-Free Casein-Free (GFCF) diet as a therapeutic intervention for Autism Spectrum Disorder (ASD). The introduction defines ASD and highlights the difficulties associated with behavior, social interaction, and communication. The discussion section explores the GFCF diet, which avoids wheat (gluten) and milk (casein) proteins. The report examines theories supporting its efficacy, including the impact on gastrointestinal functioning and the role of casomorphins. It also discusses the Microbiota-Gut-Brain-Axis (MGBA) and the potential effects of gluten and casein on gut microbiota and neurotransmitter metabolism. The report then reviews several studies, including randomized controlled trials and surveys, evaluating the GFCF diet's impact on autistic children. While some studies show positive parental responses and potential improvements in communication and social interaction, others found no significant changes in behavior or intestinal permeability. The report also addresses the nutritional adequacy of the GFCF diet. The conclusion summarizes the limited scientific evidence supporting the GFCF diet and recommends caution and professional advice before implementing it. The report emphasizes the need for further research with larger samples and extended follow-up periods.

Running head: AUTISM SPECTRUM DISORDER: INTERVENTIONS
AUTISM SPECRUM DISORDER: INTERVENTIONS: GLUTEN FREE CASEIN
FREE DIET
Name of the Student:
Name of the University:
Author note:

1AUTISM SPECTRUM DISORDER: INTERVENTIONS
Introduction
Autism Spectrum Disorder (ASD) implies a range of complex neurological and
behavioral conditions affecting the development of children at the age of 2 to 3 years (American
Psychiatric Association, 2019). Children with ASD are generally with difficulties pertaining to
behavior, social interaction and communication (National Institute of Mental Health, 2019). The
Gluten-Free Casein-Free (GfCf) diet is currently garnering scientific support as a beneficial
treatment for ASD symptom management. The following paper will critically analyze current
evidence on the efficacy of the GfCf diet in ASD.
Discussion
Gluten-Free Casein-Free Diet (GFCF)
According to Autism Canada, a GfCf diet comprises of avoidance of foods contributing
to the consumption of wheat (gluten) proteins and milk (casein) proteins in the diet and hence, is
devoid of casein containing milk and associated dairy products like cheeses, yoghurt, milk based
beverages or fermented milk products along with gluten containing grain and grain products like
wheat, oats, rye and barley. Such an elimination diet is considered to administer beneficial
behavioral impacts on children with ASD symptoms (Autism Canada, 2019).
As researched by Jarmołowska et al., (2019), the underlying theory postulated in support
of the above evidence is that ASD children possess difficulties in gastrointestinal functioning,
which limit their ability metabolize gluten and casein resulting in debilitating digestive
symptoms and hence the associated discomfort and behavioral difficulties. Additional theories
emphasize towards ‘casomorphines’ – by-products of protein digestion which have been

2AUTISM SPECTRUM DISORDER: INTERVENTIONS
evidenced to administer symptoms like confusion, restricted social interaction and reduced
reception and perception of pain in ASD children. Considering the same, a GfCf diet has been
recommended for ASD children to provide relief from gastrointestinal symptoms and the
associated issues in behavior, socialization and cognition (Delgado et al., 2017).
The associations between a GfC diet and the underlying mechanisms of the Microbiota-
Gut-Brain-Axis (MGBA) and hence, digestive processes in children with ASD have been
evidenced by Cieślińska1, Kostyra1 and Savelkoul (2017). The authors examined that the
digestion and metabolism of gluten and casein result in the secretion of small peptides like
casomorphins and gliadorphins. Such peptides overcome the Blood Brain Barrier (BBB), and
administer symptoms similar to those exerted by opioids like disrupted social interaction,
attention and maturation in the brain of autistic children. The research by Cieślińska1, Kostyra1
and Savelkoul (2017), further indicate that autistic children possess an altered gutmicrobiota as
compared to their non-autistic counterparts. Increased colonies of microbial species of
Lactobacillus and Clostridium found in the feces of autistic children have been evidenced to
contribute to alter the metabolism of catecholamines and serotonin resulting in altered
neurotransmitter metabolism and the associated symptoms of disrupted cognitive, social and
behavioral aspects in children with ASD.
Considering that a diet rich complex carbohydrates and proteins are primary sources of
energy and growth for gut microbial strains and that its associated metabolic products of short
chain fatty acids (SCFA) can alter intestinal membrane integrity (‘leaky gut’) and aggravate
ASD symptoms, authors Cieślińska1, Kostyra1 and Savelkoul (2017) hence postulated that an
elimination GfCf diet, free from gluten and casein can perpetrate the symptomatic effects and
peptide-like productions by diverse gut microbiota in ASD children, and hence, mitigate

3AUTISM SPECTRUM DISORDER: INTERVENTIONS
gastrointestinal, social, behavioral and cognitive symptoms. In criticism however, Cieślińska1,
Kostyra1 and Savelkoul (2017). Also denoted that there remains a dearth of sufficient
supportive information emphasizing the advantages of a GfCf diet in autistic children, with
evidence limited to only a few randomized controlled trials with small sample sizes.
Further, in criticism of the theoretical evidence linking gluten and casein with
gastrointestinal and cognitive dysfunctions in autistic children, the research by Pusponegoro et
al., (2015), provides useful key insights. The authors performed a double blind, randomized
controlled trial across 75 autistic children with high urinary amounts of intestinal fatty acid
binding protein (I-FABP) and behavioral issues, in which subjects were randomly allocated to
groups receiving casein-gluten or placebo for 1 week. Assessment results in the Gastrointestinal
Symptom Severity Index and the Pervasive Development Disorder Behavior Inventory did not
project any aggravation in symptoms of behavior or digestion across both groups of autistic
children. Despite the lack of association between autistic symptom progression and casein and
gluten intake, the validity and applicability of this study continues to remain questionable due to
its relatively small sample size and short intervention time period.
The lack of such associations between diet and behavior in autistic children has also been
evidenced in the double blind , randomized controlled trial peformed by Navarro et al., (2015),
which researched the impact of milk and gluten consumption as compared to placebo on
behavior and intestinal permeability in 12 autistic children for weeks. No significant changes
were however observed in terms of both intestinal permeability and behavior across the groups,
as indicated by the results obtained from Conners Parent Rating, Aberrant Behavior Checklist
and lactulos:mannitol sugar permeability test. There was also an absence of reporting of

4AUTISM SPECTRUM DISORDER: INTERVENTIONS
gastrointestinal symptoms. The results of this study continue to remain doubtful in terms of
validity, once again, due to small sample size.
In criticism of the above, positive results however, have been documented by Lange,
Hauser and Reissmann (2015), which reported results of a survey in the United Kingdom, on
exploration of parents’ views on the impact of dietary interventions on the symptoms of their
autistic children. A total of 20 to 29% of positive parental responses were reported which
indicated observed behavioral improvements in children after consumption of a GfCf diet.
Despite the comprehensiveness of the results provided by this research, the high risk of bias
indicated the need for further research. Additionally, the research by Marí-Bauset et al., (2016),
indicated lesser-than-normal values of body mass index, weight and intake of calcium, calories,
sodium and pantothenic acid on 20 Spanish children consuming GfCf diet has compared to 85
children engaging in regular dietary patterns. Reduced intake of Vitamin D were also observed in
the former group of children, indicating that despite its evidenced efficacy, the GfCf diet may not
be nutritionally adequate for autistic children in the future. Limited evidence on the advantages
of GfCf diet in children with autism has also been evidenced in the systematic review by
Piwowarczyk (2016). Of the six randomized controlled trials reviewed the authors, none of the
studies produced any statistically significant difference in terms of GfCf diet consumption and
autistic symptoms with an exception of however one trial exhibiting positive impacts on
communication and social interaction facets of autism in children indicated by results of the
Gilliam Autism Rating Scale and the Autism Diagnostic Observation Schedule.
Recommendations
Hence, from the above critical analysis, it can be observed that limited scientific evidence
exists in support of the efficacies of an GfCf diet in the management of behavioral,

5AUTISM SPECTRUM DISORDER: INTERVENTIONS
communication and social symptoms in autistic children. Further, the results of existing
supportive evidence have issues with validity in terms of high risk of bias and applicability due
to small sample size. There is hence, a need to conduct further valid research on the effects of
such interventions using larger samples and extensive follow up periods. Further, considering the
possibility of adverse nutritional consequences, researchers as well as internationally acclaimed
organization dealing with the subject must also study on long term nutritionally adequacy of the
GfCf diet. Considering the same, parents are adviced to proceed with caution, or at best, avoid
administering the diet without clinical advice (Elder et al., 2015).
Conclusion
The aforementioned paper demonstrates the range of evidence evaluating the
effectiveness of the GfCf diet as a therapeutic intervention in the management of autism of
children. At present, there lies limited evidence indicating positive impacts of this diet with a
majority of diets lacking adequacy in terms of validity and applicability. To conclude, not only is
there a need to conducted further comprehensive research in this field, but parents are also
recommended to avoid proceeding with this diet without professional advice.

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References
American Psychiatric Association. (2019). What Is Autism Spectrum Disorder?. Retrieved 23
July 2019, from https://www.psychiatry.org/patients-families/autism/what-is-autism-
spectrum-disorder.
Autism Canada. (2019). Casein Free – Autism Canada. Retrieved 23 July 2019, from
https://autismcanada.org/living-with-autism/treatments/biomedical/diets/casein-free/.
Ciéslińska, A., Kostyra, E., & Savelkoul, H. F. (2017). Treating autism spectrum disorder with
gluten-free and casein-free diet: The underlying microbiota-gut-brain axis
mechanisms. HSOA Journal of Clinical Immunology and Immunotherapy, 3.
Delgado, M. A., Fochesato, A., Juncos, L. I., & Gargiulo, P. Á. (2017). Metabolic Association
Between the Gut–Brain Axis in Autism Spectrum Disorders. In Psychiatry and
Neuroscience Update-Vol. II (pp. 465-476). Springer, Cham.
Elder, J. H., Kreider, C. M., Schaefer, N. M., & de Laosa, M. B. (2015). A review of gluten-and
casein-free diets for treatment of autism: 2005–2015. Nutrition and dietary
supplements, 7, 87.
Jarmołowska, B., Bukało, M., Fiedorowicz, E., Cieślińska, A., Kordulewska, N., Moszyńska, M.,
... & Kostyra, E. (2019). Role of Milk-Derived Opioid Peptides and Proline Dipeptidyl
Peptidase-4 in Autism Spectrum Disorders. Nutrients, 11(1), 87.
Lange, K. W., Hauser, J., & Reissmann, A. (2015). Gluten-free and casein-free diets in the
therapy of autism. Current Opinion in Clinical Nutrition & Metabolic Care, 18(6), 572-
575.

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Marí-Bauset, S., Llopis-González, A., Zazpe, I., Marí-Sanchis, A., & Suárez-Varela, M. M.
(2016). Nutritional impact of a gluten-free casein-free diet in children with autism
spectrum disorder. Journal of autism and developmental disorders, 46(2), 673-684.
National Institute of Mental Health. (2019). NIMH » Autism Spectrum Disorder. Retrieved 23
July 2019, from https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/
index.shtml.
Navarro, F., Pearson, D. A., Fatheree, N., Mansour, R., Hashmi, S. S., & Rhoads, J. M. (2015).
Are ‘leaky gut’and behavior associated with gluten and dairy containing diet in children
with autism spectrum disorders?. Nutritional neuroscience, 18(4), 177-185.
Piwowarczyk, A., Horvath, A., Łukasik, J., Pisula, E., & Szajewska, H. (2018). Gluten-and
casein-free diet and autism spectrum disorders in children: a systematic review. European
journal of nutrition, 57(2), 433-440.
Pusponegoro, H. D., Ismael, S., Firmansyah, A., Sastroasmoro, S., & Vandenplas, Y. (2015).
Gluten and casein supplementation does not increase symptoms in children with autism
spectrum disorder. Acta Paediatrica, 104(11), e500-e505.