Received: 15 November 2020 Revised: 11 October 2021 Accepted: 12 October 2021

DOI: 10.1002/eat.23631

ORIGINAL ARTICLE

Food selectivity, nutritional inadequacies, and mealtime

behavioral problems in children with autism spectrum disorder
compared to neurotypical children

pez PhD1,2
Jorge Molina-Lo | Beatriz Leiva-García PhD3 | Elena Planells PhD2,4 |
Paloma Planells PhD3

1
Faculty of Education, Psychology and Sport
Sciences, University of Huelva, Huelva, Spain Abstract
2
Institute of Nutrition and Food Technology. Objective: To evaluate body composition, nutritional status through food selectivity
Biomedical Research Center, Health Sciences
and degree of inadequate intake, and mealtime behavior in children with autism spec-
Technological Park, University of Granada,
Granada, Spain trum disorder (ASD) compared to neurotypical children.
3
Faculty of Dentistry, Complutense University Method: A cross-sectional case–control study was carried out in 144 children
of Madrid, Madrid, Spain
4
(N = 55 with ASD; N = 91 with neurotypical children) between 6 and 18 years of
Department of Physiology, Faculty of
Pharmacy, University of Granada, Granada, age. Body composition, nutritional intake, food consumption frequency (FFQ), and
Spain
mealtime behavior were evaluated.
Correspondence Results: Results showed a greater presence of children with a low weight (18.4%
Elena Planells, Institute of Nutrition and Food
ASD vs. 3.20% comparison group) and obesity (16.3% ASD vs. 8.6% comparison
Technology. Biomedical Research Center,
Health Sciences Technological Park, University group) in the ASD group for body mass index (BMI) categories (p = .003; number
of Granada, Avenida del Conocimiento, 18100
needed to take [NNT] = 8.07). The presence of obesity in ASD children compared to
– Armilla, Granada, Spain.
Email: [email protected] the comparison group was even higher when considering the fat component (47.5%
ASD vs. 19.4% comparison group, p = .002; NNT = 10.3). ASD children had greater
Jorge Molina-Lo
pez, Faculty of Education,
Psychology and Sport Sciences, University of intake inadequacy (50% ASD vs. 22% comparison group, p = .014; NNT = 3.58), high
Huelva, Avenida de las Fuerzas Armadas S/N,
food selectivity by FFQ (60.6% ASD vs. 37.9% comparison group, p < .037;
21007, Huelva, Spain.
Email: [email protected] NNT = 4.41), and more eating problems (food rejection, limited variety, disruptive
behavior), compared to neurotypical children (p = .001).
Funding information
Mutua Madrileña Research Foundation Conclusion: Children with ASD showed an unbalanced body composition toward
both underweight and obesity, a greater degree of inadequate intake, high food
Action Editor: Ruth Striegel Weissman
selectivity as indicated by their consumption frequency, and more disturbed eating
behavior than children with neurotypical development. We suggest monitoring nutri-
tional inadequacies and implementing nutritional strategies to expand the variety of
foods children with ASD consume.

KEYWORDS
anthropometric parameters, autism spectrum disorder, food selectivity, mealtime behavior,
nutrient intake

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.

Int J Eat Disord. 2021;54:2155–2166. wileyonlinelibrary.com/journal/eat 2155

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2156 MOLINA-LÓPEZ ET AL.

1 | I N T RO DU CT I O N ASD is still a prominent area of research, based on dietary preferences

for processed foods, snacks, and sweets and the frequent rejection of
Autism spectrum disorders (ASD) is a behaviorally defined complex fruits and vegetables (Sharp et al., 2013). Since the literature on the
neurodevelopmental syndrome characterized by impairments in social assessment of ASD children's nutritional status is limited, to our
communication and restricted and repetitive behaviors, interests and knowledge, there are few studies (Bandini et al., 2010; Hyman
activities, as well as abnormalities in sensory reactivity (American et al., 2012; Marí-Bauset et al., 2017) that have performed a detailed
Psychiatric Association, 2013) that are frequently associated with dif- comprehensive assessment of intake using the reference technique of
ferent comorbidities such as disruptive behavior, gastrointestinal 72-h food diaries, complemented by food consumption frequency.
symptoms, and eating problems (Peverill et al., 2019). These atypical The existence of differences in anthropometric measurements
eating patterns are often governed by food rejection/denial or a pref- between children with ASD and neurotypical children has been
erence for certain kinds of food (Bandini et al., 2017; Wentz, Björk, & described as possibly related to severe food selectivity and mealtime
Dahlgren, 2019), and may lie in a sensory-associated physiological behavioral problems, as well as to special diets and/or gastrointestinal
alterations probably caused by their behavioral problems (Ashley, problems in children with ASD (Kamal Nor, Ghozali, & Ismail, 2019).
Steinfeld, Young, & Ozonoff, 2020; Peverill et al., 2019). Although there are different methods by which to assess overweight
ASD children's atypical eating patterns include mealtime rituals and obesity in children and adolescents (Chan & Woo, 2010), body
(Hubbard, Anderson, Curtin, Must, & Bandini, 2014), food selectivity composition methods demonstrate high accuracy in the assessment of
(Bandini et al., 2017; Sharp et al., 2018), and disruptive behavior at adiposity (Jensky-Squires et al., 2008). To date, very few studies have
mealtimes (Dovey et al., 2019; Leader, Tuohy, Chen, Mannion, & evaluated body composition in children with ASD, and the existing
Gilroy, 2020; Murphy, Zlomke, VanOrmer, & Swingle, 2020). Food research has produced inconsistent or even contradictory results. On
selectivity is one of the most common eating problems in children the one hand, Castro et al. (2017) concluded that a large percentage
with ASD and is an important cause of concern because of its nega- of children and adolescents with ASD had total overweight or obesity
tive impact upon nutritional adequacy (Kral et al., 2015; Sharp with truncal adiposity, and there was a significant percentage of
et al., 2013) and anthropometric parameters (Criado et al., 2018; underweight participants. In contrast, a recent study (Esteban-
Sharp et al., 2018), as well as the family stress generated at mealtime Figuerola, Morales-Hidalgo, Arija-Val, & Canals-Sans, 2021) revealed
(Thullen & Bonsall, 2017). Severe forms of feeding concerns in ASD the absence of significant differences in bioelectrical impedance anal-
meet the diagnostic criteria for avoidant-restrictive food intake disor- ysis in children and adolescents with ASD, compared to children with
der (ARFID), a psychiatric diagnosis that recognizes ASD as a risk fac- neurotypical development. Therefore, further studies are needed to
tor for nutritional concerns associated with food selectivity (Eddy & analyze body composition imbalances in this concrete population,
Thomas, 2019). with a view to associating such alterations with atypical behavioral
Previous review (Cermak, Curtin, & Bandini, 2010) and meta- patterns and the intake inadequacy.
analysis studies (Sharp et al., 2013) concluded a higher food selectivity Based on the above, the present study was carried out to evalu-
and nutrient insufficiency in ASD children compared to control chil- ate body composition, nutritional status through food selectivity and
dren. Nevertheless, they point out a lack of complete nutritional degree of inadequate intake, as well as mealtime behavior in children
assessment in ASD child. Nowadays, there is still a need of analytical with ASD, compared to neurotypical children. We hypothesized that
studies that cover all aspects involved in nutritional intake in children children with ASD would (a) present an unbalanced body composition,
with ASD, including food intake frequency by groups, as well as the (b) have altered macro- and micronutrient food intake, (c) have food
number of deficiencies and the dietary preferences in ASD that may selectivity as indicated by their consumption frequency, and
explain conflicting results among past reports. To date, a few studies (d) exhibit more disruptive behavior than children with neurotypical
(Bandini et al., 2010; Hyman et al., 2012) have assessed in detail nutri- development.
ent intake in children with ASD, based on 72-h food diaries describing
insufficient intake of certain nutrients such as vitamins A, C, B6, B9
(folate), B12, D, E, and K, or minerals such as phosphorus, zinc, cal- 2 | METHOD
cium (Ca), or iron (Fe). Very few studies (Marí-Bauset, Llopis-González,
Zazpe, Marí-Sanchis, & Morales Suárez-Varela, 2017) have addition- 2.1 | Participants
ally analyzed food consumption habits through the application of the
food frequency questionnaire (FFQ) to identify unbalanced diets due The present cross-sectional, observational case–control study was
to excess or absence in terms of the consumption of certain food carried out at Madrid Complutense University and the University of
groups. It has been suggested that children with ASD could be at risk Granada (Spain) between January 2016 and December 2018. This
of suffering nutritional inadequacies (Sharp et al., 2018) resulting in was a multidisciplinary study involving specialists in dentistry, nutri-
negative middle- to long-term consequences for growth and develop- tion, physiology, and ASD. The study sample comprised 144 children
ment (Bandini et al., 2017; Graf-Myles et al., 2013). Moreover, the rel- (51 children with ASD and 93 neurotypical children) and convenience
ative contribution of food selectivity and dietary disturbance to the sampling was used to select participants attending special schools and
increased risk of overweight and obesity that has been observed in primary schools. The neurotypical children were selected from the
 1098108x, 2021, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23631 by Nat Prov Indonesia, Wiley Online Library on [19/08/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MOLINA-LÓPEZ ET AL. 2157

same inclusive public centers that have specific classrooms for chil- researcher. The following measurements were obtained: weight,
dren with ASD. ASD children aged between 6 and 18 years were diag- body mass index (BMI), and lean mass and fat mass expressed as a
nosed based on the criteria in the Diagnostic and Statistical Manual of percentage of total body fat (fat mass index [FMI]).
Mental Disorders V (DSM-V), but disorder severity was not consid-
ered. The comparison group members were selected from a geograph-
ical setting and socioeconomic context similar to that of the children 2.2.2 | Seventy-two-h food diary
with ASD. The exclusion criteria for both groups were as follows: use
of dietary supplements, receiving treatment or following a special diet A 72-h recall questionnaire was used to record the participant's food
(e.g., gluten- and casein-free), any medical condition (endocrine, meta- and drink consumption over a 3-day period. This type of 3-day food
bolic diseases, etc.) that could influence food intake, use of drugs diary is currently considered the gold standard among the methods
(e.g., stimulants, atypical antipsychotics, tricyclic antidepressants, ste- for assessing diet (Barrett-Connor, 1991). The questionnaire was
roids, and mood stabilizers) that could affect food intake; not attend- based on recall of food intake for 2 days of the week, in addition to
ing study interview appointments, and not completing nutritional one weekend day, in order to avoid weekly mean data registry bias
records properly. attributable to special consumption habits on weekends. The food
After contacting the school administration, the center notified the intake information was obtained from individual interviews with the
parents and coordinated an informative meeting. After the initial children's parents or legal representatives, conducted by a registered
session, those parents who decided to allow their children to partici- dietitian. Experts on the research team held informative workshops
pate were given an informed consent form to sign. At the first before data collection and resolved any possible doubts through
appointment, before the study began, the parents received an expla- telephone support. The data collected on food and beverage con-
nation of the tests that would be applied, as well as data confidential- sumption were finally converted to absolute values referring to
ity in compliance with Spanish legislation, and informed consent for energy consumption, macro and micronutrient intake, and percentage
children's participation was obtained. The study was approved by the intake adequacy for each nutrient (recommended daily allowance
Ethics Committee of Hospital Clínico Universitario San Carlos [RDA]), using Nutriber software (version 1.1.5, Barcelona, Spain).
(Madrid, Spain). The children's parents or legal representatives were Nutritional data obtained were compared against the Spanish
scheduled to attend an informative meeting during which the study's food composition tables (Mataix, 2011). Vitamin and mineral intake
objectives, the relevance of the expected results, and the study's sig- was also compared against the recommended dietary intake (DRI) for
nificance to the children's health were explained. For both groups, we both the Spanish population and the European Union (Cuervo
excluded families who declined to participate and those who we were et al., 2009). Intake adequacy or inadequacy was determined by com-
unable or failed to provide complete nutritional records. paring each participant's real intake to the recommended intake for
each nutrient, with two cut-off points: insufficient intake (less than
75% of the DRI) and excessive intake (above the DRI). In addition, to
2.2 | Instruments and procedures assess the children's specific degree of inadequate intake, we calcu-
lated the total number of macronutrients and micronutrients for
2.2.1 | Body composition and anthropometric which there was insufficient intake and established three cut-off
measurements points: mildly inadequate intake (insufficient intake of one to five
nutrients), moderately inadequate intake (insufficient intake of 6 to
Height was measured using a stadiometer (precision 0.1 cm, Secca 10 nutrients), and highly inadequate intake (insufficient intake
220, Spain) while the children remained static in the anatomical posi- of over 10 nutrients) (Marí-Bauset, Llopis-González, Zazpe-García,
tion with their heels together. The children were weighed (wearing Marí-Sanchis, & Morales-Suárez-Varela, 2015).
light clothes) barefoot in the anatomical position with their feet
and hands on the electrodes. Body composition measurements
were obtained via multifrequency bioelectrical impedance (Tanita 2.2.3 | Food frequency questionnaire
MC-980 MA Multifrequency Segmental Body Composition Analyzer,
Barcelona, Spain). The analyzer complies with the applicable European The FFQ was used to determine the daily, monthly, and annual
standards (93/42EEC, 90/384EEC) for use in the medical industry. consumption frequency of each food groups, based on a list of over
The impedance between each child's feet and hands, respectively, 200 foods. For each participant, we determined the percentage
was measured while an alternating current (50 kHz, 90 mA) was pas- adequacy of the consumption for the different food groups in relation
sed through the entire body. The participants or their parents/legal to the recommendations of the Spanish Society of Community Nutri-
representatives were informed in advance about the conditions that tion (SENC) (Aranceta Bartrina et al., 2016). The participants were
had to be observed prior to measurement: no vigorous exercise for at classified into two categories: (a) an FFQ score below the rec-
least 12 h before the test, no food or drink for at least 3 h before the ommended servings of a given food group, or (b) an FFQ score above
test, and urination immediately before measurement. All anthropometric the recommended servings based on the food pyramid proposed by
measurements were taken at the same time and recorded by the same the SENC for each food group (Aranceta Bartrina et al., 2016). Those
 1098108x, 2021, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23631 by Nat Prov Indonesia, Wiley Online Library on [19/08/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2158 MOLINA-LÓPEZ ET AL.

food groups without a recommendation were expressed as servings loadings (Hendy et al., 2013) and, subsequently, the mean scores for
consumed per week. Food selectivity was assessed using the informa- each dimension were calculated. Regarding alpha coefficients, 0.79
tion reported on the FFQ, defined as the degree of adequacy, and was found for the limited variety factor, 0.69 for the food refusal fac-
used to classify the participants into two categories according to the tor, and 0.69 for the disruptive behavior factor. The parents or legal
percentage of foods each child refused among those offered, that is, representatives were asked to score the children's mealtime eating
showing no intake frequency: (a) nonfood selectivity (an FFQ food behavior according to the frequency of incidence of each situation in
score of less than 33% of the total foods); or (b) high food selectivity the last 6 months on a scale ranging from 1 to 5, where 1 = never,
(an FFQ score of over 33% of the total foods) (Chistol et al., 2018; 2 = rarely, 3 = occasionally, 4 = often, 5 = almost always.
Curtin et al., 2015).

2.3 | Statistical analysis

2.2.4 | Brief assessment of mealtime behavior in
children The data were analyzed using the SPSS version 25.0 statistical pack-
age for MS Windows (SPSS Inc. Chicago, IL) and expressed as the
Mealtime behavior was evaluated using the BAMBIC (Hendy, mean and SD in the descriptive analysis. The variables were standard-
Seiverling, Lukens, & Williams, 2013). The questionnaire was adminis- ized using the Shapiro–Wilk test with Lilliefors correction. Homosce-
tered to participants' parents to assess three common food problems: dasticity was determined with the Levene test. A comparative
(a) limited variety of foods, (b) rejection of foods, and (c) disruptive study of the sample characteristics in children with ASD and the
behavior at mealtimes. The questionnaire comprised a total of comparison group was performed using analysis of covariance
10 items, with scores for each BAMBIC subscale based on a 5-point (ANCOVA) for continuous variables. The model was adjusted for age.
Likert scale. Each item's scores were initially multiplied by the factor Comparative analysis of daily energy, macronutrient and

TABLE 1 Main characteristics and body composition distribution of children with autism spectrum disorder and children with neurotypical
children

ASD Neurotypical
children (n = 51) children (n = 93)

Mean SD Mean SD F Covariate age F p-Value (Cohen's d) [NNT]

Age 9.57 1.67 12.8 2.98 - - 53.3 .001 (1.29)
BMI Z score 0.44 1.32 0.25 0.63 17.8 .001 2.12 .147 (.246)
n % of n % of
children children
BMI percentile classification
Underweight 9 18.4 3 3.2 .003a [8.07]
Healthy weight 22 44.9 65 69.9
Overweight 10 20.4 17 18.3
Obesity 8 16.3 8 8.6
Fat mass percentile classification
Healthy 18 45.0 52 55.9 .002b [10.3]
Overfat 3 7.50 23 24.7
Obese 19 47.5 18 19.4

Note: The continuous variables data were expressed as the mean and standard deviation (SD). The categorical variables were expressed number and
percentage of subjects. ANCOVA analysis was used to compare values for ASD and the comparison group (p < .05 being considered significant). The
model has been corrected by the age factor. Cohen's d coefficient for continuous variables were provided (.20: small effect; .50: intermediate effect; .80
and higher: large effect) (Lenhard & Lenhard, 2017). Number needed to take was also calculated for categorical variables as the number of children with
altered body compartment relative to the total number of children for each group (NTT: < 4: strong effect; 4 to 9: moderate effect; > 9 weak effect)
(Kraemer & Kupfer, 2006). The body mass index (BMI) was classified into four categories in accordance to the CDC growth charts for the BMI by age (for
boys or girls) to obtain the percentile category: underweight, less than the 5th percentile; healthy weight, 5th percentile to 85th percentile; overweight,
85th to 95th percentile; obese, equal to or greater than the 95th percentile (Nagy et al., 2014). The fat mass index was classified into three categories in
accordance to the TANITA healthy body fat ranges for children by age (for boys or girls): healthy, overfat and obese (McCarthy et al. 2006).
Abbreviations: ASD, Autism spectrum disorder; BMI, body mass index; ES, effect size.
a
p-Value obtained in Chi-square test using the Bonferroni analysis. χ2 = 13.754, df = 4, p value < .003.
b
p-Value obtained in Chi-square test using the Bonferroni analysis. χ2 = 12.845, df = 2, p value < .002.
 TABLE 2 Comparative analysis of daily macro and micronutrient intake and adequacy in autism spectrum disorder children compared to neurotypical children
ASD children (n = 51) Neurotypical children (n = 93)
Daily nutrient intake
Macronutrients Median 25th–75th quartile Insufficient Excess Median 25th–75th quartile Insufficient Excess χ 2 (NTT) Z p-Value (Cohen's d)
MOLINA-LÓPEZ ET AL.

Energy (kcal/day) 1879.0 1,314.0–2,453.0 15 (34.9) 17 (39.5) 1,658.0 1,484.0–1947.0 9 (15.3) 27 (45.8) *(7.92) 1.06 .290 (.211)

Carbohydrates (% of total energy) 48.4 40.2–50.9 20 (46.5) 8 (18.6) 46.8 44.1–50.5 18 (30.5) 13 (22.0) (11.9) .07 .943 (.014)

Proteins (% of total energy) 18.0 15.4–19.5 0 (0) 44 (93.0) 18.5 16.3–20.0 1 (1.7) 58 (98.3) ( 60.0) 1.24 .214 (.248)

Fats (% of total energy) 33.6 31.1–38.2 15 (34.9) 17 (39.5) 36.5 32.7–40.2 6 (10.2) 40 (67.8) *(6.01) 1.81 .070 (.365)

Fiber (g/day) 15.9 10.4–21.6 16 (37.2) 19 (44.2) 15.1 13.4–19.7 5 (8.5) 38 (64.4) *(5.18) 0.09 .929 (.046)

Vitamins

Thiamine (mg/day) 1.20 0.97–1.67 0 (0) 40 (93) 1.18 0.84–1.42 2 (3.4) 56 (94.9) ( 30.5) 1.47 .140 (.295)

Riboflavin (mg/day) 1.50 1.11–1.94 5 (11.6) 27 (62.8) 1.56 1.21–1.74 4 (6.8) 51 (86.4) *(24.5) .26 .792 (.052)

Niacin (mg/day) 21.3 16.2–25.5 1 (2.30) 42 (97.7) 20.6 16.8–25.7 2 (3.40) 51 (91.5) ( 99.4) .34 .732 (.068)

Vitamin B6 (mg/day) 3.20 2.34–4.87 22 (51.2) 13 (30.2) 3.29 2.39–4.11 19 (32.2) 23 (39) (10.5) .27 .786 (.311)

Pantothenic acid (mg/day) 1.77 1.30–2.17 9 (20.9) 22 (51.2) 1.52 1.25–2.07 5 (8.5) 41 (69.5) (10.5) 1.55 .121 (.054)

Biotin (mg/day) 5.10 3.65–7.61 4 (9.30) 35 (81.4) 4.86 3.69–7.76 1 (1.70) 56 (94.9) (14.6) .17 .863 (.034)

Folate (mg/day) 225.4 162.2–304.8 3 (7) 40 (93) 197.5 172.5–269.0 1 (1.70) 58 (98.3) (20.5) .82 .412 (.163)

Vitamin B12 (mcg/day) 5.85 3.94–11.5 2 (4.70) 37 (86) 5.82 4.14–8.05 4 (6.80) 48 (81.4) (19.1) .40 .687 (.080)

Vitamin C (mg/day) 115.5 74.9–153.6 41 (95.3) 0 (0) 91.9 59.6–129.3 56 (94.9) 3 (5.10) (8.78) 1.96 .050 (.396)

Retinol (mcg/day) 585.3 453.2–1,008.0 17 (39.5) 20 (46.5) 798.8 609.1–948.2 4 (6.80) 47 (79.7) *(4.54) 1.57 .117 (.314)

Vitamin D (mg/day) 4.35 2.60–6.33 20 (46.5) 17 (39.5) 7.06 4.34–10.0 18 (30.5) 32 (54.2) (11.9) 2.12 .034 (.429)

Vitamin E (mg/day) 8.18 5.42–11.7 20 (46.5) 17 (39.5) 6.91 5.25–9.39 17 (28.8) 23 (39) (10.6) 1.82 .069 (.366)

Minerals

Sodium (mg/day) 2.87 2.34–3.76 0 (0) 14 (32.6) 3.08 2.51–3.75 0 (0) 19 (32.3) ( ) .71 .479 (.141)

Potassium (mg/day) 2,745.0 2,224.0–3,447.0 14 (32.6) 21 (48.8) 2,633.0 2,186.0–3,175.0 12 (20.3) 31 (52.5) (13.0) .58 .565 (.115)

Calcium (mg/day) 940.0 684.4–1,206.0 9 (20.9) 21 (48.8) 1,007.0 900.3–1,135.0 5 (8.5) 48 (81.4) *(10.5) .66 .507 (.132)

Magnesium (mg/day) 292.1 239.8–358.8 14 (32.6) 16 (37.2) 289.8 244.1–367.9 6 (10.2) 43 (72.9) *(6.03) .31 .758 (.061)

Phosphorous (mg/day) 1,261.0 863.8–1702.0 2 (4.7) 33 (76.7) 1,282.0 1,090.0–1,478.0 3 (5.1) 47 (79.7) ( 253) .34 .735 (.067)

Iron (mg/day) 12.1 9.39–18.69 12 (27.9) 24 (55.8) 11.5 9.77–15.8 5 (8.5) 45 (76.3) *(7.14) .88 .378 (.175)

Cooper (mg/day) 0.73 0.60–1.09 12 (27.9) 17 (39.5) 0.69 0.53–0.88 14 (23.7) 25 (42.4) (37.8) 1.14 .253 (.228)

Zinc (mg/day) 6.41 4.94–9.58 31 (72.1) 6 (14) 6.17 5.28–7.59 35 (59.3) 19 (32.2) (9.59) .35 .727 (.069)

Selenium (mcg/day) 46.7 32.5–59.7 12 (28.6) 26 (61.9) 64.2 44.7–84.3 4 (6.80) 50 (84.7) *(6.46) 2.41 .016 (.491)

Iodine (mcg/day) 82.7 48.8–227.8 19 (44.2) 21 (48.8) 221.1 58.3–271.0 13 (22) 45 (76.3) *(7.94) 2.46 .014 (.502)

Note: Data for continuous variables were expressed as median and quartiles at the 25th and 75th. The categorical variables were expressed number and percentage of subjects. Wilcoxon rank-sum test analysis was used to compare values for ASD and
neurotypical children. The model was corrected by the age factor. Bonferroni-corrected significance levels for multiple comparisons were calculated for nutritional analyses of macronutrients (p = .05/5, being considered significant if p < .01), vitamins (p = .05/12,
being considered significant if p < .004) and minerals (p = .05/10, being considered significant if p < .005). Cohen's d coefficient for continuous variables were provided (.20: small effect; .50: intermediate effect; .80 and higher: large effect) (Lenhard &
Lenhard, 2017), being calculated from the Z of the applied nonparametric test (Fritz et al., 2012). Number needed to take was also calculated for categorical variables (NTT: < 4: strong effect; 4 to 9: moderate effect; > 9 weak effect) (Kraemer & Kupfer, 2006). The
DRI percentages were calculated according to the Spanish recommendations (Cuervo et al., 2009). The macronutrient distribution was expressed as percentage of total energy consumed. Intake inadequacy was determined by comparing each participant's real
intake to the recommended intake for each nutrient, with two cut-off points: an intake below the 75% of DRI was classified as “insufficient intake”; an intake above the 100% of DRI was classified as “intake excess.”
Abbreviations: ASD, autism spectrum disorder; DRI, dietary reference intake.
*p-value obtained in Chi-square test using the Bonferroni adjustment (p < .05).
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 2160

TABLE 3 Food consumption frequency and adequacy in children with autism spectrum disorder and neurotypical children

ASD children (n = 51) Neurotypical children (n = 93)

25th–75th 25th–75th
Food groups Reference Median quartile <R >R Median quartile <R >R χ 2 (NTT) Z p-Value (Cohen's d)
Potatoes, rice, bread, wholemeal 4–6 s/d 2.36 2.00–2.75 100 - 2.29 1.86–2.57 100 - - 1.28 .201 (.265)
bread, pasta
Vegetables >2 s/d 2.38 2.10–3.57 14.7 35.3 2.00 1.50–2.96 46.7 25.0 *( 5.26) 2.62 .009 (.575)
Fruits >3 s/d 2.07 1.72–2.72 84.8 - 2.03 1.21–2.67 83.3 - ( 341) .40 .691 (.083)
Milk and dairy 2–4 s/d 2.29 1.73–2.58 42.4 3.0 2.30 2.12–2.64 40.0 0 (168) 1.34 .180 (.281)
Fish 3–4 s/w 4.50 3.94–6.43 8.8 64.7 3.76 2.75–5.25 26.7 43.3 ( 7.75) 2.47 .014 (.485)
Lean meats, poultry and eggs 3–4 s/w 6.75 6.00–7.98 - 94.1 6.39 5.20–7.50 - 91.7 ( 46.8) .47 .639 (.049)
Legumes 2–4 s/w 2.00 2.00–3.00 12.0 4.0 2.00 2.00–3.00 13.3 1.7 ( 95.2) .86 .392 (.560)
Nuts 3–7 s/w 1.00 0.01–2.00 84.8 - 0.25 0.01–1.00 91.7 - ( 51.9) 1.14 .253 (.235)
Sausages and meat fatsa Occasional 0.86 0.57–1.14 6.1 93.9 1.00 0.59–1.28 3.3 95.0 (40.1) .88 .378 (.183)
a
Sweets, snacks and soft drinks Occasional 1.82 1.16–1.88 - 93.9 1.99 1.53–2.53 - 100 (17.5) 2.78 .006 (.601)
Butter, margarine and pastriesa Occasional 1.00 0.86–1.21 0 97.8 2.30 0.71–1.28 3.3 96.7 ( 31.0) .99 .323 (.205)

Note: The continuous variables data were expressed as the median and quartiles at the 25th and 75th. The categorical variables were expressed number and percentage of subjects. Wilcoxon rank-sum test
analysis was used to compare values for ASD and neurotypical children. The model was corrected by the age factor. Bonferroni-corrected significance levels for multiple comparisons were calculated for food
consumption frequency (p = .05/11, being considered significant if p < .004). Cohen's d coefficient for continuous variables were provided (.20: small effect; .50: intermediate effect; .80 and higher: large effect)
(Lenhard & Lenhard, 2017), being calculated from the Z of the applied nonparametric test (Fritz et al., 2012). Number needed to take was also calculated for categorical variables (NTT: < 4: strong effect; 4 to 9:
moderate effect; > 9 weak effect) (Kraemer & Kupfer, 2006). Food frequency adequacy was expressed as servings/day and servings/week. Reference values for food consumption frequency were proposed by
the Spanish Community Nutrition Society (SENC) (Aranceta Bartrina et al., 2016).
Abbreviations: ASD, autism spectrum disorder; s/d, servings/day; s/w, servings/week; < R = food frequency consumption below the reference recommendation; > R = food frequency consumption above the
reference recommendation.
a
If occasional servings are recommended or if there is no specific recommendation for a food group, intake is reported as servings/day.
MOLINA-LÓPEZ ET AL.

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MOLINA-LÓPEZ ET AL. 2161

TABLE 4 Nutritional inadequacy, food selectivity and mealtime behavior in children with autism spectrum disorder and neurotypical children

ASD Neurotypical
children (n = 51) children (n = 93) p-Value (Cohen's
Mean SD Mean SD F d) [NNT]
Nutritional inadequacy (number of
nutrients)
Macronutrients inadequacy 4.48 2.06 3.47 1.50 7.90 .010 (.588)
Micronutrients inadequacy 7.71 4.12 5.33 3.46 9.84 .003 (.637)
Total inadequate intake 11.9 5.84 8.81 4.72 8.29 .008 (.595)
FFQ adequacy 51.0 8.70 47.1 7.79 3.96 .048 (.478)
Frequency of problematic child mealtime
behaviors
Food rejection 3.05 1.13 2.37 0.53 16.7 .001 (.869)
Limited variety 1.20 2.89 3.05 1.76 15.4 .001 (.840)
Disruptive behavior 2.95 0.85 2.49 0.32 15.5 .001 (.827)
Degree of inadequate intake, n
(percentage)
Low inadequacy (1–5 nutrients) 4 10.5% 13 22.0% - .014a [3.58]
Moderate inadequacy (6–10 nutrients) 15 39.5% 33 55.9% -
High inadequacy (> 10 nutrients) 19 50.0% 13 22.0% -
Degree of FFQ adequacy, n (percentage)
Nonselectivity (>33% of total items) 13 39.4% 36 62.1% - .037b [4.41]
High food selectivity (<33% of total 20 60.6% 22 37.9% -
items)

Note: The continuous variables data were expressed as the mean and SD. The categorical variables were expressed number and percentage of subjects.
ANCOVA analysis was used to compare values for ASD and the comparison group. The model has been corrected by the age factor. Bonferroni-corrected
significance levels for multiple comparisons were calculated for nutritional inadequacy (p = .05/4, being considered significant if p < .01) and the frequency
of problematic child mealtime behaviors (p = .05/3, being considered significant if p < .02). The BAMBIC classified the scores into three categories: food
rejection, limited food variety, and disruptive behavior (Hendy et al., 2013). Cohen's d coefficient for continuous variables were provided (.20: small effect;
.50: intermediate effect; .80 and higher: large effect) (Lenhard & Lenhard, 2017). Number needed to take was also calculated for categorical variables (NTT:
< 4: strong effect; 4 to 9: moderate effect; > 9 weak effect) (Kraemer & Kupfer, 2006). For the categorical variable degree of inadequate nutrient intake,
low and moderate inadequacy computed as unfortunate outcome. The nutritional inadequacy was classified into three categories according to the range of
nutrients with inadequate intake (Mari-Bauset et al., 2015): low, inadequate intake of 1 to 5 nutrients; moderate, inadequate intake of 6 to 10 nutrients;
high, inadequate intake greater than 10 nutrients. Food selectivity was assessed using the information reported on the FFQ, defined as the degree of
adequacy, and used to classify the participants into two categories according to the percentage of foods each child refused among those offered, that is,
showing no intake frequency: nonselectivity, an FFQ food score of less than 33% of the total foods; high food selectivity, an FFQ score of over 33% of the
total foods (Chistol et al., 2018; Curtin et al., 2015).
a
p-Value obtained in the Chi-square test using Bonferroni's analysis. χ 2 = 8.491, df = 3, p < .05.
b
p-Value obtained in the Chi-square test using Bonferroni's analysis. χ 2 = 4.351, df = 1, p < .05.

micronutrient intake, FFQ score and adequacy in ASD children com- FFQ (being considered significant if p < .004), nutritional inade-
pared to neurotypical children was performed using the Wilcoxon quacy (being considered significant if p < .01) and the frequency of
rank-sum test, and the data were expressed as the median and problematic child mealtime behaviors (being considered significant if
interquartile ranges. Behavioral problems during meals were deter- p < .02). Cohen's d coefficient for continuous variables were provided as
mined using ANCOVA to explore the differences between the a more standardized measure of effect size to indicate the magnitude of
mean scores obtained for the ASD children versus the comparison the between-group differences, being calculated from the Z of the
group, adjusting for age. A chi-squared test was used to analyze applied nonparametric test according to Fritz, Morris, and Richler (2012)
the sample distribution based on BMI and FMI, and proportions of and classified as described by Lenhard and Lenhard (2017) (.20: small
ASD and neurotypical children who showed both insufficient effect; .50: moderate effect; .80 and higher: large effect). The number
intake and an excessive intake of vitamins or minerals. Bonferroni- needed to take (NNT) was performed to report the effect size of the cat-
corrected significance levels for multiple comparisons were calcu- egorical variables considering the prime rates of each of the variables of
lated for nutritional analyses of macronutrients (being considered interest (NNT < 4: strong effect; 4 to 9: moderate effect; >9 weak
significant if p < .01), vitamins (being considered significant if effect). The NNT applied in the present study is the answer to the ques-
p < .004) and minerals (being considered significant if p < .005), tion “How many children with ASD do you have to see to find one more
 1098108x, 2021, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23631 by Nat Prov Indonesia, Wiley Online Library on [19/08/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2162 MOLINA-LÓPEZ ET AL.

‘failure’ (e.g., BMI disturbance, nutritional inadequacy, or food selectivity) ASD were seen to present high nutritional inadequacy versus 22% of the
than if you had sampled neurotypical children” (Kraemer & Kupfer, comparison group (strong effect). Moreover, 60.6% of the children with
2006; Striegel-Moore et al., 2009). ASD showed high food selectivity versus 37.9% of the neurotypical chil-
dren (moderate effect). Lastly, the former showed greater food rejection,
disruptive behavior, and limited variety (large effect).
3 | RESULTS

Table 1 reports the characteristics of the ASD and neurotypical children 4 | DI SCU SSION
included in the study. Statistically significant age differences were
observed; specifically, the children with ASD were younger than the The present study compared body composition, nutritional status, and
comparison group. The group comparison of the mean z score for age- mealtime eating behaviors in children with ASD versus neurotypical
adjusted BMI was not statistically significant. However, the sample distri- children. The main findings were a prevalence of underweight and
bution analysis revealed significant between-group differences with a obesity of 18.4 and 16.3%, respectively, among the children with ASD
moderate effect for BMI categories; specifically, comparatively more chil- on considering BMI. The figure in turn increased to 47.5% for the
dren with ASD were in the low weight category (18.4% vs. 3.20% in the latter fat mass category on considering the body fat component.
comparison group) and also in the obese category (16.3% vs. 8.6% in the Furthermore, although no differences in median nutrient intake were
comparison group). Significantly more children with ASD were also found observed between the groups, 50% of the children with ASD showed
to be in the obese category when stratifying by fat percentage (47.5% high inadequacy for nutrient intake due to inadequate intakes
vs. 19.4% in the comparison group; small effect). corresponding to more than 10 nutrients, high food selectivity, as well
Table 2 shows the results of the comparative analysis referred to as more disruptive mealtime behavioral problems compared to
median energy, macro- and micronutrient intake, and intake adequacy neurotypical children.
in the study groups. Despite the fact that the median energy was simi- In children with ASD, a number of studies have recorded contra-
lar in both groups, a larger percentage of children with ASD were dictory data regarding anthropometrical measures. For instance,
below the RDA (34.9% versus 15.3% in the comparison group; moder- Neumeyer et al. (2018) evaluated children with ASD and neurotypical
ate effect). Similarly, more children with ASD had greater inadequacy children, and recorded similar BMI values in both groups. This is
of fat and fiber (moderate effect). With regard to vitamins and min- consistent with the study of Malhi, Venkatesh, Bharti, and
erals, although no differences between groups were observed in Singhi (2017) in children between 4 and 10 years of age, where BMI
terms of the median intakes of the analyzed micronutrients after likewise was found to be similar in both groups. In contrast, in Spain,
adjusting for multiple comparisons, more children with ASD presented Marí-Bauset et al. (2015) recorded a greater prevalence of low weight
greater inadequacy of vitamins such as vitamin B2 and retinol, and of in children with ASD. These authors observed no significant differ-
minerals such as calcium (Ca) (20.9% vs. 8.5% in the neurotypical com- ences in food intake but suggested that the underlying cause could be
parison group), magnesium (Mg) (32.6% vs. 10.2% in the comparison atypical eating behavior or food selectivity—though they did not spe-
group), iron (Fe) (27.9% vs. 8.5% in the comparison group), selenium cifically investigate these factors. On the other hand, Hyman
(Se) (28.6% vs. 6.8% in the comparison group) and iodine (I) (44.2% et al. (2012) found 5- to 11-year-old children with ASD to have a
vs. 22.0% in the comparison group) (small to moderate effect). greater incidence of low weight, while those between 2 and 5 years
Table 3 in turn shows the adequacy of mean food consumption of age showed a greater incidence of overweight and obesity, com-
frequency in the study population. After adjusting for multiple com- pared to neurotypical children. In our study, there was a greater pres-
parisons, no differences were observed between groups in the con- ence of low weight as well as a higher frequency of children with
sumption of any of the analyzed food groups—though there was a obesity in the ASD group when BMI was considered (moderate
trend toward statistical significance for the consumption of vegetables effect). This is in agreement with the study published by Castro
(p = 0.009) and sweets, snacks, and soft drinks (p = 0.006). Most of et al. (2017), who used bioelectrical impedance as a reference tech-
the children in both groups exceeded the recommended consumption nique for body composition. Based on the above, it could be con-
of occasional foods such as sweets, snacks, and soft drinks, while they cluded that children with ASD might be characterized by a deviation
did not frequently consume recommended foods such as potatoes, toward both low weight and obesity, with a similar distribution of
rice, bread, wholemeal bread, pasta, fruit, or nuts. In addition, more both extremes.
children in the neurotypical comparison group showed a lower Evaluating food intake is a key element in nutritionally assessing a
frequency of vegetable consumption than in the ASD group. population. Several studies have reported on nutritional inadequacies
Table 4 reports nutritional inadequacy based on the number of in children with ASD (Sharp et al., 2018; Sharp, Berry, Burrell, Scahill, &
nutrients with an inadequate intake, food selectivity according to the McElhanon, 2020). In this regard, Adams, Johansen, Powell, Quig, and
FFQ score, and the evaluation of mealtime eating problems. Children Rubin (2011) affirmed that insufficient protein intake, metabolic
with ASD showed greater nutritional inadequacy for both macronutrients imbalances or alterations in protein digestion in children with ASD
and micronutrients (moderate effect). When the children were classified may be associated to increased gastrointestinal problems. In fact,
according to the degree of inadequacy, one-half of the children with these authors reported that nutritional status depends not only on
 1098108x, 2021, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23631 by Nat Prov Indonesia, Wiley Online Library on [19/08/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MOLINA-LÓPEZ ET AL. 2163

intake but also on digestion, absorption, metabolic processing and the importance of an adequate diet, lower FFQ scores for certain
metabolic demand. Regarding dietary intake, children with ASD essential foods were observed in the group of children with ASD,
consume 16% less calories, a greater percentage of carbohydrates, resulting in a more limited food variety.
37% less protein, and 29% less fats (Neumeyer et al., 2018). Interest- Atypical mealtime behavior and food selectivity are common in
ingly, from 34.9 to 39.5% of our children with ASD showed an altered children with ASD (Sharp et al., 2013, 2018). In a previous study, we
consumption of calories—both insufficiency and excess—this being reported altered mealtime eating behavior in relation to severe food
mainly due to an unbalanced intake of certain macronutrients such as selectivity and its association to oral health in children with ASD
fats and fiber, with a moderate effect and described by the homoge-
pez, 2019).
(Leiva-García, Planells, Planells Del Pozo, & Molina-Lo
neous response despite the sample size in both groups. This fact could Similarly, prior evidence (Chistol et al., 2018; Murphy et al., 2020;
also be related to the abovementioned distribution of the children Peverill et al., 2019) would confirm such eating problems in these
between extreme nutritional status categories (underweight and children, including food rejection, limited variety, unbalanced intake
obese). In contrast to other studies, a high protein intake was and food consumption frequency, and mealtime behavioral problems,
observed in both groups—this being consistent with data where such food preferences would have been attributed to the
previously reported in Spanish children (Serra-Majem, Ribas-Barba, influence of other factors such as sensory sensitivity and familial
Pérez-Rodrigo, & Bartrina, 2006). In relation to micronutrient intake, food preferences (Bandini et al., 2017). It has been highlighted that
the adjustment of multiple comparisons showed the children with ASD children with ASD exhibit poorer behavior during meals, as well as
to have no differences in absolute intake of all the assessed micro- lower dietary quality, though food consumption questionnaires were
nutrients versus the comparison group. These findings are in contrast not used to evaluate this aspect (Johnson et al., 2014). Other studies
to the observations of a recent meta-analysis (Esteban-Figuerola, (Bandini et al., 2017; Zimmer et al., 2012) have also recorded a
Canals, Fernández-Cao, & Arija Val, 2019) that recorded lower intakes greater risk of nutritional insufficiency when children with ASD
of certain vitamins and minerals in children with ASD compared to exhibit food selectivity. The assessment of intake alterations, the
healthy controls. In our opinion there may be two explanations for this. application of the FFQ, and the statistical adjustment for multiple
First, our study applied a more conservative statistical analysis, avoiding comparisons are among the strengths of the present study, evidenc-
overestimations or false positives of the differences between the ing that although no differences between groups were observed in
two groups that could appear in other studies (Esteban-Figuerola absolute values of intake and FFQ, a greater percentage of children
et al., 2019). Second, the children with ASD would be less likely to with ASD presented highly inadequate intake (insufficient intake of
suffer from insufficient nutrient intake, mainly because of greater 6–10 or more nutrients), as well as high food selectivity, as deter-
parental control over food consumption (Hyman & Johnson, 2012). mined by the FFQ—though with a weak effect size. We therefore
Although used in routine practice, 72-h food diaries have a num- should be cautious when generalizing such differences. In line with
ber of limitations that may result in the underestimation of food our findings, Sharp et al. (2018) found that 78.5% of the children with
intake. The data they afford therefore must be interpreted with cau- ASD followed a diet with an inadequate intake of five or more nutri-
tion (Burrows, Martin, & Collins, 2010). The FFQ is considered to be ents. Additionally, these food selectivity and nutritional inadequacies
an essential tool in the qualitative assessment of nutrient intake, tak- were greater in the group of children with ASD, who were the chil-
ing into account our Mediterranean diet model based on the food pyr- dren with the most altered mealtime behavior (moderate effect),
amid proposed by the SENC (Aranceta Bartrina et al., 2016). Again, explaining that these differences would stem from the greater alter-
adjustment for multiple comparisons revealed similar food consump- ation and homogeneous response of these behaviors in children
tion in both groups, although there was an imbalance in the consump- with ASD.
tion of certain food groups such as potatoes, rice, bread, wholemeal From a holistic perspective, in order to provide an answer to the
bread, pasta, fruits, milk and dairy products, or nuts, where a high per- observed alterations in body composition in our children with ASD, a
centage of children showed consumption below the recommenda- longitudinal study (Bandini et al., 2017) evaluating 18 adolescents
tions. In contrast, a moderate percentage of children over-consumed with ASD found correlations between changes in weight and the vari-
lean meats, poultry and eggs, and other foods where consumption ety of food consumed. Moreover, Sharp et al. (2018) evaluated
should be occasional—which in the case of lean meats, poultry and 279 patients (70 of whom had ASD) over a 24-month period, and
eggs would be consistent with the recorded protein intake. Neverthe- found those subjects that exhibited severe food selectivity and had
less, it should be taken into account that both the results published by five or more nutritional inadequacies to be more likely to present
Marí-Bauset et al. (2017) and our own findings suggest good adher- mealtime behavioral issues—though this severe food selectivity was
ence to the reference Mediterranean diet, albeit with shortcomings in not associated to compromised growth or obesity. Similarly, Castro
the intake of certain fundamental food groups. Despite the methodo- et al. (2016) underscored the relationship between increased over-
logical heterogeneity involved, other studies (Herndon, DiGuiseppi, weight and obesity and greater food-related behavioral problems in
Johnson, Leiferman, & Reynolds, 2009; Schreck, Williams, & children with ASD, and a relationship has also been reported between
Smith, 2004) have obtained results similar to our own. Although the a higher BMI and greater nutritional deficiencies due to selective pref-
findings of the present study are encouraging in that they reflect erences for processed foods, sweets, and soft drinks (Shmaya, Eilat-
awareness on the part of the parents of children with ASD regarding Adar, Leitner, Reif, & Gabis, 2015). Our findings in the form of altered
 1098108x, 2021, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/eat.23631 by Nat Prov Indonesia, Wiley Online Library on [19/08/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2164 MOLINA-LÓPEZ ET AL.

body composition, inadequate intake, food selectivity, and altered AUTHOR CONTRIBU TIONS
mealtime behavior thus underscore the importance of monitoring
pez and Beatriz-Leiva García carried out the collec-
Jorge Molina-Lo
children with ASD who have food problems, in order to identify possi- tion, analysis, and interpretation of data, and drafted the manuscript.
ble nutritional imbalances and introduce dietetic measures to improve
pez, Beatriz-Leiva García, Elena Planells, and Paloma
Jorge M. Lo
their health, autonomy and quality of life. Planells recruited the patients and collected nutritional data. Elena
The present study has some limitations that should be consid-
pez,
Planells, and Paloma Planells designed the study. Jorge M. Lo
ered. We did not measure the degree of ASD, although the children Beatriz-Leiva García, Elena Planells helped in the analysis and inter-
with ASD who participated in the study were enrolled in specialized
pez, Beatriz-Leiva García helped to
pretation of the data. Jorge M. Lo
centers and had been previously officially diagnosed. Another limi- draft the manuscript. All authors read and approved the final
tation is the use of questionnaires, which, although validated, manuscript.
depend on the parent participation and subjective opinion for com-
pletion. Thus, mealtime behavioral problems were not obtained DATA AVAILABILITY STAT EMEN T
through direct observation, which could have avoided bias. Last, The data that support the findings of this study are available on
the lack of standardized values for nutritional recommendations request from the corresponding author. The data are not publicly
between countries and the variations in nutritional recommenda- available due to privacy or ethical restrictions.
tions for different age groups make it very difficult to compare
nutritional intake findings between different studies conducted on OR CID
children with ASD—hence the diversity of the results observed in
pez
Jorge Molina-Lo https://orcid.org/0000-0003-2516-5226
the literature as reported in a meta-analysis carried out by Esteban- Elena Planells https://orcid.org/0000-0001-8291-4110
Figuerola et al. (2019). As a strength, the assessment of nutritional Paloma Planells https://orcid.org/0000-0003-3307-4535
status by combining body composition with food intake and fre-
quency of food consumption, as well as mealtime behavior, and sta- RE FE RE NCE S
tistical analysis for multiple comparisons, would demonstrate new Adams, J. B., Johansen, L. J., Powell, L. D., Quig, D., & Rubin, R. A. (2011).
findings revealing a possible overestimation of nutritional differ- Gastrointestinal flora and gastrointestinal status in children with
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Burrows, T. L., Martin, R. J., & Collins, C. E. (2010). A systematic review of
The present study was supported in part by grants from the Mutua
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Madrileña Research Foundation. The authors gratefully acknowledge with the method of doubly labeled water. Journal of the American Die-
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