The rate of obesity amongst children is increasing rapidly and becoming a serious global health problem with an increase in associated chronic health risks, like diabetes, heart disease, sleep disorders, metabolic problems, musculo-skeletal problems, etc. Studies have shown that the incidence of overweight and obesity is even higher in the autistic population. The rates of overweight and obesity in children on the autistic spectrum is estimated to be 33% for overweight and 18% for obesity, which is higher than the rates for neurotypical developing children. (Hill AP, 2015)

There are several risk factors which could contribute to overweight and obesity in the Autistic Spectrum group. A Malaysian study found older child age, high maternal BMI, older paternal age, low physical activity, low likelihood of food refusal and high likelihood of food selectivity to be risk factors for high BMI in ASD children. (Kamal Nor Norazlin, 2019)

Health and Nutrition

Before venturing into management strategies, one has to exclude nutritional deficiencies and health problems. Commonly associated nutritional problems associated with obesity are iron deficiency, zinc deficiency, and lead toxicity. We are seeing more and more insulin resistance in children, which contributes to ánd is a result of midline weight gain. Metabolic disorders, mitochondrial dysfunction and low motor function also lead to obesity and need to be tested for.

Gut-brain connection

Gastro-intestinal health is pivotal in the prevention and management of obesity and overweight. Gastro-intestinal disease and -inflammation is common in autistic children. Underlying changes in the gut microbiome (organism component of the gastro-intestinal tract) has been shown to determine weight control. (Gupta, 2020).

The body’s energy balance is controlled by the hypothalamus in the brain, but overeating triggers the activation of inflammatory and stress response pathways and resultant hormonal dysregulation. (Kaneko K, 2019). Low grade systemic inflammation and oxidative stress, fired by a typical Western diet is associated with food addiction, reducing feedback inhibition pathways for food restriction.

Self-selective eating

ASD children are commonly self-selective about food. Children will typically resonate towards nutrient deficient, high calorie foods, so their food selection needs to be managed from a very early stage. A higher BMI is associated with food selectivity and children with a higher BMI seem to select specific foods, mostly crunchy textures and carbohydrates. I find the most challenging developmental stage for food refusal, manipulation and development of sensory sensitivity related to food the 2-4-year-old group. This is where good guidelines must already be put into place.

Management strategies and parental guidance

One of the first things to do when a child is developing sensory resistance to certain foods, is to do sensory integration therapy and work with desensitisation techniques. Repetitive offering of healthy options and positive feedback around eating are good investments. Speech therapy and behaviour management techniques could all contribute to better outcomes. It is well known that most negative eating patterns are maintained by negative feedback. Creating a positive, stress free environment is a good start to developing balanced feeding behaviour. Positive reinforcement helps. Food reinforcers for behavioural modification can play a negative role in that a child becomes motivated to eat more and develop impulsivity around food intake. Care should be taken around certain behavioural techniques and the association with food rewards,

Sleep

Up to 98.7% of autistic children have some form of sleep disturbance. The recommended duration of sleep for 5-10-year-olds is at least 10-13 hours. Dysregulated sleep has consequences on growth, circadian rhythms, metabolic processes, behaviour and eating habits. Several studies have alluded to the inverse relationship between sleep duration and weight gain. Just as sleep deprivation can lead to overweight and obesity, obesity in its turn can lead to obstructive sleep apnoea, thus sleep deprivation. There are several strategies and medications or supplements to improve sleep in children, so best is to team up with a professional who can help with effective sleep management.

Physical activity

There are several factors associated with ASD which would lead to less time spent doing physical activities. Social and behavioural challenges narrow down the options. Related  motor skills deficits or compromised coordination limit sport opportunities and preferences. There is a major shift toward indoor activities. Schooling for the special needs group often happens in smaller groups, where organised sport is less freely available. In the autistic neurodiverse group, the resonance is toward technology and the safe social environment thereof, which leads to more sedentary time and less physically active time. Developing a balance and applying technology in moderation has become a particular struggle in todays’ world. Complicated by the addictive nature of technology, self-motivation in this regard is mostly lacking. The trick here is to find some physical activity that is fun for the individual, relatively easy and sustainable.

Genetic determinants

Genetics definitely underpins the risk of childhood obesity. Lifestyle factors in families also play a role. Interestingly genetic vulnerabilities are linked to both autism and obesity. Some researchers have found specific genetic links between the 2 conditions, where they have been able to show 36 common genes between these 2 conditions. (Dhaliwal, 2019). There are several genetic/chromosomal disorders associated with obesity and often related to autism, such as Down -, Prader-Willi -, Smith-Lemli-Opitz -, William syndrome, and others. With genomics SNP analysis being available some of the epigenetic pathways can be examined and addressed.

Medication

Most children presenting autism will be offered a prescription for an anti-psychotic medication (Risperidone or Aripiprazole) somewhere down the line. Unfortunately, the side-effects of these commonly used medications have a bad imprint on sugar metabolism. In certain individuals the combination of this medication with their genetic constitution leads to weight gain and eventually insulin resistance and diabetes. Care must be taken to limit, or preferably completely avoid, refined carbohydrates, sugar and sweets when using this medication.

Comorbid conditions, such as ADHD, anxiety, OCD and depression are commonly associated with autism. The medication used to manage these conditions (SSRIs, methylphenidate, atomoxetine, etc.) also have a negative impact on weight control, so measures need to be taken to limit the impact. Best is to make good food choices and to try to avoid hunger and cravings that lead to the intake of high calorie, nutrient deficient foods.

Obesity in children is associated with social, emotional and physical challenges, which compound the difficulties associated with the autistic spectrum presentation. Because Autistic Spectrum Diverse children have several problems that result in poor socialisation and social acceptance, successfully preventing and/or managing obesity could contribute positively to inclusion.