Nutritional Status and Dietary Behaviors of Children with Intellectual or Developmental Disabilities in Saudi Arabia: A Systematic Review

Figures & data

Figure 1 Flowchart illustrating the selection process for studies included in the systematic review.

Table 1 Characteristics of Selected Studies Included in the Systematic Review (n = 31)

No.	Studies (Authors, Year)	Type of Cases*	Study Design	Study Objectives	Study Location	Data Collection Period	Sample Size	Age (Years)	Cases Recruitment	Control Recruitment
1	Al Husain, 2003a^Citation22	DS	Cross-sectional study	Assess the prevalence of overweight/obesity and establish reference BMI percentile curves for children with DS	Riyadh	January to December 2001	Cases: 785 (M/F: 393/392) Control: 989 (M/F: 591/470)	0–5	Genetic and the General Pediatric Clinics at King Khalid University Hospital, Riyadh	NR
2	Al Husain, 2003b^Citation23	DS	Cross-sectional study	Construct growth charts for Saudi children under 5 years of age with DS	Riyadh	January to December 2001	Cases: 785 (M/F: 393/392) Control: 989 (M/F: 591/470)	0–5	Genetic and the General Pediatric Clinics at King Khalid University Hospital, Riyadh	NR
3	Alsulaimani et al, 2014^Citation24	ASD	Case-control study	Determine possible risk factors for autism	Taif	June 2011 to May 2013	Cases: 60 (M/F: 46/14) Control: 120 (M/F: 92/28)	1.6–8	Mental Health Clinic integrated in Pediatric Clinic, Prince Mansour Military Hospital, Taif	Outpatient Clinics, Prince Mansour Military Hospital, Taif
4	Alhusaini et al, 2018^Citation25	DS	Cross-sectional study	Compare physical activity levels between children with DS and typically developing children	Riyadh	NR	Cases: 37 (M) Control: 41 (M)	8–12	Al-Nahda School for Down Syndrome and Down Syndrome Charitable Association, Riyadh	Two regular schools, Riyadh
5	Allam et al, 2020^Citation26	DS	Cross-sectional study	Compare the walking capacity of children with DS to typically developing children	Riyadh	NR	Cases: 37 (M) Control: 41 (M)	8–12	Al-Nahda School for Down Syndrome and Down Syndrome Charitable Association, Riyadh	Two regular schools, Riyadh
6	Mohamed et al, 2013^Citation27	DS	NR	Investigate dietary practice and physical activity among children with DS	Riyadh	February to May 2011	Cases: 108 (M/F: NR) Control: 113 (M/F: NR)	5–12	Al-Nahda School for Down Syndrome and Down Syndrome Charitable Association, Riyadh	Healthy, age-matched siblings
7	Bindayel, 2021^Citation28	DS	Cross-sectional study	Determine the prevalence of overweight and obesity in children and adolescents with DS	Riyadh	NR	Cases: 48 (M/F: 22/26) Control: 27 (M/F: 12/15)	3–18 3–12 (children) 13–18 (adolescents)	The Voice of Down Syndrome Society (SAUT) and Down Syndrome Charitable Association (DSCA), Riyadh	Healthy, age-matched siblings
8	Samarkandy et al, 2012^Citation29	DS	Case-control study	Assess nutritional status and prevalence of obesity among children with DS	Riyadh	February to May 2011	Cases: 108 (M/F: 62/46) Control: 113 (M/F: 60/53)	5–12	Al-Nahda School for Down Syndrome and Down Syndrome Charitable Association, Riyadh	Healthy, age-matched siblings
9	Alahmari et al, 2022^Citation30	ASD	Case-control study	Compare the nutritional status of children with ASD to typically developing children	NR	November 2020 to March 2021	Cases: 70 (M/F: NR) Control: 85 (M/F: NR)	7–12	Autism centers (location: NR)	One elementary school (location: NR)
10	Hammouda et al, 2018^Citation31	ASD	Case-control study	Identify nutritional risk factors that predispose to autism	Madinah	February to April 2014	Cases: 30 (M/F: NR) Control: 36 (M/F: NR)	2–10	Pediatric Psychiatry Outpatient Clinic and Autism Day Care Center, Al-Amal Psychiatric Hospital, Madinah	Taibah University and Nabaa AL-Maref Nursery for the young age group, Madinah
11	Ashour et al, 2018^Citation32	ASD, DS, CP	Cross-sectional study	Investigate the association between dental caries and obesity	Makkah	October to December 2016	ASD: 41 (F) DS: 52 (F) CP: 17 (F)	6–17	Nineteen special care schools, Makkah	NA
12	Al-Blowi et al, 2020^Citation33	CP	Retrospective cohort study	Evaluate the nutritional status of children with CP	Madinah	January 2012 to December 2016	Cases: 119 (M/F: 56/63)	5.9 ± 3.9 (mean ± SD)	Maternity and Children’s Hospital, Madinah	NA
13	Kasnawi & Jambi, 2020^Citation34	ASD	Cross-sectional study	Investigate the association of Food Selectivity domains with nutritional adequacy in autistic children	Two cities in the western region	September to December 2014	Cases: 32 (M/F: 28/4)	6–12	Six autism centres in two cities in the western region	NA
14	Mohamed et al, 2021^Citation35	ASD, DS, CP, ID	Cross-sectional study	Assess the association between dental caries and obesity	Taif	September 2018 to March 2019	ASD: 107 (M/F: NR) DS: 70 (M/F: NR) CP: 43 (M/F: NR) ID: 123 (M/F: NR)	6–12	Twenty-five regular schools, Taif (only children with special needs were selected)	NA
15	Almuneef et al, 2019^Citation36	CP	Cross-sectional study	Assess the nutritional status of children with CP	Riyadh	January to August 2015	Cases: 74 (M/F: 44/30)	1–12	Cerebral Palsy Clinic, Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh	NA
16	Elshorbagy et al, 2018^Citation37	ADHD	Case-control study	Evaluate serum vitamin D levels in children diagnosed with ADHD	Taif	December 2015 to January 2017	Cases: 50 (M/F: 28/22) Control: 40 (M/F: 21/19)	7–14	Pediatric Neuropsychiatric Outpatient Clinic, Al Hada and Taif Military Hospitals, Taif	Primary health care centers, Taif
17	El-Ansary et al, 2018^Citation38	ASD	Cross-sectional study	Determine the relationship between vitamin D levels and selected biomarkers	Riyadh	NR	Cases: 28 (M) Control: 27 (M)	3–12	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
18	Mostafa & AL-Ayadhi, 2012^Citation39	ASD	Cross-sectional study	Investigate the relationship between serum vitamin D levels and anti-myelin-associated glycoprotein auto-antibodies	Riyadh	NR	Cases: 50 (M/F: 39/11) Control: 30 (M/F: 24/6)	5–12	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
19	Al-Gadani et al, 2009^Citation40	ASD	NR	Measure oxidative stress/antioxidant status in autistic children	NR	NR	Cases: 30 (M/F: 22/8) Control: 30 (M/F: 20/10)	3–15	NR	NR
20	Azhari, 2023^Citation41	ASD	Prospective study	Assess vitamin D levels in ASD children and the effects of vitamin D supplementation	NR	January to July 2022	Cases: 11 (M/F: 9/2)	4–12	Will Be Center for Special Needs and The Leading Academy for Autism, (location: NR)	NA
21	El-Ansary et al, 2011a^Citation42	ASD	NR	Compare plasma fatty acid profiles of autistic children with typically developing children	Riyadh	NR	Cases: 26 (M/F: NR) Control: 26 (M/F: NR)	4–12 (Cases) 4–11 (Control)	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
22	El-Ansary et al, 2010^Citation43	ASD	NR	Investigate the role of selected ions related to energy metabolism in deterioration accompanied ASD	NR	NR	Cases: 30 (M/F: 22/8) Control: 30 (M/F: 20/10)	3–15	NR	NR
23	El-Ansary et al, 2011c^Citation44	ASD	NR	Investigate the relationship between concentrations of selected ions and proinflammatory and proapoptotic biomarkers	Riyadh	NR	Cases: 25 (M) Control: 16 (M)	4–12 (Cases) 4–11 (Control)	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
24	El-Ansary, 2017^Citation45	ASD	NR	Assess the relative abundance of lead, mercury, and selenium in red blood cells (RBCs)	Riyadh	NR	Cases: 35 (M) Control: 30 (M)	3-12	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
25	Mostafa & AL-Ayadhi, 2015^Citation46	ASD	Case-control study	Investigate plasma levels of PUFAs and serum carnitine in relation to GI manifestations	Riyadh	NR	Cases: 100 (M/F: 78/22) Control: 100 (M/F: 78/22)	3–10	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
26	El-Ansary et al, 2011b^Citation47	ASD	NR	Compare plasma relative concentrations of essential fatty acids of autistic children with typically developing children	Riyadh	NR	Cases: 25 (M/F: NR) Control: 16 (M/F: NR)	4–12 (Cases) 4–11 (Control)	Autism Research and Treatment Center, Faculty of Medicine, King Saud University, Riyadh	Well Baby Clinic at King Khalid University Hospital, Riyadh
27	AlOmar et al, 2021^Citation48	ASD	Case-control study	Study the role of a vitamin D deficient diet in the development of ASD	Arar & Dammam	NR	Cases: 100 (M/F: 76/24) Control: 100 (M/F: 53/47)	3–10	Child psychiatry clinic of Al Amal Mental health complex, Arar; Shumua Al Amal Centre for Special Education and Rehabilitation; Shamah Autism Centre and Prince Sultan Rehabilitation Complex, Dammam	Department of Paediatrics, Arar Maternity and Child Health Centre, Arar; Baraam AlSharqiyah School, Dammam
28	Bin Ammar & Almuhaini, 2022^Citation49	ASD	Case-control study	Evaluate the dietary habits of autistic children	Hail	March to April 2022	Cases: 80 (M/F: 54/26)	4–12	Tawasol Medical Centres for Autism and Hdka Medical Centre for Autism, Hail	NA
29	Bin Eid et al, 2022^Citation50	ASD	NR	Assess sleep in both children with ASD and typically developing children	Riyadh	NR	Cases: 81 (M/F: 67/14) Control: 78 (M/F: 36/41)	5–12	One large special care school and two ASD centres, Riyadh	Regular schools, Riyadh
30	Murshid, 2014^Citation51	ASD	Cross-sectional study	Assess the diet, oral hygiene and dental health of autistic children	Riyadh	May 2012	Cases: 344 (M/F: 261/83)	3–14	Three autistic rehabilitation centers, Riyadh	NA
31	Al-Hammad, 2015^Citation52	CP	NR	Determine dietary practices of children with CP	Riyadh	NR	Cases: 157 (M/F: 90/67)	2–10	Disabled Children’s Association Center (DCAC), Riyadh	NA

Notes: *ASD: Autism Spectrum Disorder; DS: Down Syndrome; CP: Cerebral Palsy; ADHD: Attention Deficit Hyperactivity Disorder; ID: Intellectual Disability; NA: Not Applicable; NR: Not Reported; M: Male; F: Female.

Table 2 Risk of Assessment Bias for Selected Studies Included in the Systematic Review (n = 31)

No.	Studies (Authors, Year)	Q1*	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Rating
1	Al Husain, 2003a^Citation22	Y	U	Y	Y	NA	Y	Y	Y	N	N	Neutral
2	Al Husain, 2003b^Citation23	Y	Y	Y	Y	NA	Y	Y	Y	U	N	Positive
3	Alsulaimani et al, 2014^Citation24	Y	Y	Y	N	NA	Y	Y	Y	Y	N	Positive
4	Alhusaini et al, 2018^Citation25	Y	N	Y	Y	NA	Y	Y	Y	Y	Y	Neutral
5	Allam et al, 2020^Citation26	Y	N	Y	Y	NA	Y	Y	U	Y	Y	Neutral
6	Mohamed et al, 2013^Citation27	Y	Y	Y	N	NA	Y	Y	Y	Y	N	Positive
7	Bindayel, 2021^Citation28	Y	Y	Y	Y	NA	Y	Y	Y	Y	Y	Positive
8	Samarkandy et al, 2012^Citation29	Y	Y	Y	N	NA	Y	Y	Y	Y	N	Positive
9	Alahmari et al, 2022^Citation30	Y	N	Y	N	NA	Y	Y	Y	Y	Y	Neutral
10	Hammouda et al, 2018^Citation31	Y	U	Y	N	NA	Y	Y	Y	Y	N	Neutral
11	Ashour et al, 2018^Citation32	Y	Y	N	N	NA	Y	Y	Y	Y	N	Neutral
12	Al-Blowi et al, 2020^Citation33	Y	Y	N	N	NA	Y	Y	Y	Y	N	Neutral
13	Kasnawi & Jambi, 2020^Citation34	Y	Y	N	N	NA	Y	Y	Y	Y	N	Neutral
14	Mohamed et al, 2021^Citation35	Y	Y	N	N	NA	Y	Y	Y	Y	Y	Neutral
15	Almuneef et al, 2019^Citation36	Y	Y	N	Y	NA	Y	Y	Y	Y	Y	Neutral
16	Elshorbagy et al, 2018^Citation37	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Positive
17	El-Ansary et al, 2018^Citation38	Y	Y	Y	U	NA	Y	Y	Y	Y	Y	Positive
18	Mostafa & AL-Ayadhi, 2012^Citation39	Y	Y	Y	N	NA	Y	Y	Y	Y	Y	Positive
19	Al-Gadani et al, 2009^Citation40	Y	U	Y	N	NA	Y	Y	Y	N	N	Neutral
20	Azhari, 2023^Citation41	Y	Y	N	N	NA	Y	Y	Y	Y	Y	Neutral
21	El-Ansary et al, 2011a^Citation42	Y	Y	Y	N	NA	Y	Y	Y	U	Y	Positive
22	El-Ansary et al, 2010^Citation43	Y	Y	Y	N	NA	Y	Y	Y	N	Y	Positive
23	El-Ansary et al, 2011c^Citation44	Y	Y	Y	N	NA	Y	Y	Y	N	Y	Positive
24	El-Ansary, 2017^Citation45	Y	Y	Y	N	NA	Y	Y	Y	Y	Y	Positive
25	Mostafa & AL-Ayadhi, 2015^Citation46	Y	Y	Y	N	NA	Y	Y	Y	Y	Y	Positive
26	El-Ansary et al, 2011b^Citation47	Y	Y	Y	N	NA	Y	Y	Y	U	Y	Positive
27	AlOmar et al, 2021^Citation48	Y	Y	Y	N	NA	U	N	Y	N	Y	Neutral
28	Bin Ammar & Almuhaini, 2022^Citation49	Y	Y	N	N	NA	N	Y	Y	U	Y	Neutral
29	Bin Eid et al, 2022^Citation50	Y	Y	Y	Y	NA	Y	Y	Y	U	Y	Positive
30	Murshid, 2014^Citation51	Y	Y	N	Y	NA	Y	Y	Y	Y	N	Neutral
31	Al-Hammad, 2015^Citation52	Y	Y	N	N	NA	Y	Y	Y	Y	Y	Neutral

Notes: *Q: Question; Y: Yes; N: No; NA: Not Applicable; U: Unclear.

Table 3 Anthropometric Assessment Reported in Selected Studies Included in the Systematic Review (n = 15)

No.	Studies (First Author, Year)	Type of Cases*	Age (years) range, mean ± SD	Height (cm) mean ± SD	Weight (kg) mean ± SD	BMI (kg/m2) mean ± SD	BMI Categories n (%)	Others
1	Al Husain, 2003a^Citation22	DS, M (n = 393)	0–0.5			15.0 ± 2.2
			0.5–1			16.6 ± 2.3
			1–2			16.7 ± 2.7
			2–3			16.3 ± 1.6
			3–4			16.4 ± 1.6
			4–5			17.1 ± 2.9
		Control, M (n = 591)	0–0.5			16.4 ± 2.3
			0.5–1			17.5 ± 1.8
			1–2			17.1 ± 1.8
			2–3			16.4 ± 3.0
			3–4			15.1 ± 1.6
			4–5			15.0 ± 1.3
		P value	0–0.5			0.0002
			0.5–1			0.0106
			1–2			0.2344
			2–3			0.7989
			3–4			0.0001
			4–5			0.0001
		DS, F (n = 392)	0–0.5			13.6 ± 2.2
			0.5–1			15.7 ± 1.9
			1–2			15.9 ± 2.0
			2–3			15.8 ± 2.0
			3–4			16.0 ± 1.5
			4–5			16.5 ± 2.3
		Control, F (n = 470)	0–0.5			16.4 ± 1.9
			0.5–1			17.5 ± 1.9
			1–2			17.1 ± 2.6
			2–3			15.5 ± 1.7
			3–4			14.9 ± 1.4
			4–5			14.8 ± 1.8
		P value	0–0.5			0.0001
			0.5–1			0.0001
			1–2			0.0003
			2–3			0.3714
			3–4			0.0001
			4–5			0.0001
2	Al Husain, 2003b^Citation23	DS, M (n = 393)						Head circumference (cm)
			0–0.5	56.4 ± 6.3	4.9 ± 1.74			38.02 ± 3.5
			0.5–1	66.1 ± 2.9	7.3 ± 1.4			41.9±2.3
			1–2	74.99 ± 5.9	9.5 ± 2.1			43.7 ± 2.1
			2–3	84.2 ± 5.4	11.63 ± 1.9			45.6 ± 2.5
			3–4	88.1 ± 8.3	13.0 ± 1.7			46.9 ± 1.99
			4–5	95.8 ± 10.9	15.95 ± 3.3			48.2 ± 2.4
		DS, F (n = 392)						Head circumference (cm)
			0–0.5	55.9 ± 5.3	4.35 ± 1.4			36.73 ± 2.64
			0.5–1	65.23 ± 3.6	6.7 ± 1.2			40.99 ± 1.7
			1–2	73.5 ± 6.2	8.6 ± 1.7			43.4 ± 2.1
			2–3	81.75 ± 3.9	10.6 ± 1.7			44.9 ± 1.97
			3–4	89.0 ± 4.9	12.7 ± 1.99			46.3 ± 2.3
			4–5	96.5 ± 6.96	15.5 ± 3.6			48.3 ± 2.5
3	Alsulaimani et al, 2014^Citation24	ASD (n = 60)	1.6–8, 3.1 ± 1.3	95 ± 10	15 ± 5
		Control (n = 120)	1.6–8, 3.1 ± 1.3	96 ± 10	14 ± 4
		P value		0.812	0.531
4	Alhusaini et al, 2018^Citation25	DS (n = 37)	8–12, 10.22 ± 1.31	127.41 ± 15.50	42.10 ± 16.28	24.43 ± 7.82	UWT: 0 (0.0%) NWT: 11 (29.7%) OWT: 13 (35.1%) Obese: 13 (35.1%)
		Control (n = 41)	8–12, 10.53 ± 1.71	138.02±14.49	41.94 ± 21.26	21.23 ± 4.50	UWT: 0 (0.0%) NWT: 26 (63.4%) OWT: 8 (19.5%) Obese: 7 (17.1%)
		P value	0.28	0.003	0.97	0.23	NR
5	Allam et al, 2020^Citation26	DS (n = 37)	8–12, 10.22 ± 1.31	127.4 ± 15.49		24.42 ± 7.81
		Control (n = 41)	8–12, 10.52 ± 1.17	138.02 ± 14.49		21.23 ± 4.5
		P value	0.282	0.003		0.028
6	Mohamed et al, 2013^Citation27	DS, M (n = NR)	5–12, 8.2 ± 1.7	108 ± 9.9	22.2 ± 7.7	19.1 ± 4.1
		Control, M (n = NR)	5–12, 8.9 ± 1.4	124 ±12.9	26.1 ± 7.8	16.9 ± 3.4
		P value	0.115	0.001	0.054	0.013
		DS, F (n = NR)	5–12, 7.9 ± 1.5	105.75 ± 8.3	20.4 ± 6.3	18.5 ± 3.1
		Control, F (n = NR)	5–12, 8.1 ± 1.6	115.1 ± 10.1	21.5 ± 4.9	16.3 ± 1.9
		P value	0.523	0.001	0.921	0.039
7	Bindayel, 2021^Citation28	DS, Children (n = 28)	3–12, 7 ± 2	114.8 ± 11.3	26.3 ± 10.0	19.3 ± 4.0	UWT: 1 (4%) NWT: 8 (29%) OWT: 6 (21%) Obese: 13 (46%)	Lean Body Mass (kg): 10.5 ± 5.7 Fat Mass (kg): 22.3 ± 8.3 Body Fat (%): 38.89 ± 13.8 Ideal Body Fat (%): 15.88 ± 1.4
		Control, Children (n = 17)	3–12, 8 ± 3	116.6 ± 27.0‡	27.6 ± 10.6	19.7 ± 3.5‡	UWT: 0 (0%) NWT: 4 (33%)‡ OWT: 4 (33%) Obese: 4 (33%)
		P value	0.167	0.841	0.676	0.783	0.775
		DS, Adolescents (n = 20)	13–18, 15 ± 2	145.0 ± 8.3	59.02 ± 13.0	27.9 ± 5.5	UWT: 0 (0%) NWT: 5 (25%) OWT: 4 (20%) Obese: 11 (55%)	Lean Body Mass (kg): 14.4 ± 5.1 Fat Mass (kg): 34.7 ± 6.6 Body Fat (%): 35.30 ± 11.6 Ideal Body Fat (%): 20.05 ± 5.8
		Control, Adolescents (n = 10)	13–18, 17 ± 3	161.1 ± 22.0	55.8 ± 9.2	22.6 ± 5.8	UWT: 2 (20%) NWT: 4 (40%) OWT: 3 (30%) Obese: 1 (10%)
		P value	0.188	0.009	0.494	0.029	0.038
8	Samarkandy et al, 2012^Citation29	DS (n = 108)	5–12			17.8 ± 3.6	UWT: 0.0 (0.0%) NWT: 61 (56.5%) OWT: 22 (20.4%) Obese: 25 (23.1%)	Triceps Skinfold Thickness (mm): 9.1 ± 3.2 Excess Subcutaneous Fat (%): 9.3%
		Control (n = 113)	5–12			15.1 ± 2.7	UWT: 0.0 (0.0%) NWT: 99 (87.6%) OWT: 8 (7.1%) Obese: 6 (5.3%)	Triceps Skinfold Thickness (mm): 8.6 ± 2.6 Excess Subcutaneous Fat (%): 2.7%
		P value				0.03	<0.0001	Triceps Skinfold Thickness (mm): <0.001 Excess Subcutaneous Fat (%): 0.036
9	Alahmari et al, 2022^Citation30	ASD (n = 70)	7–12, 8.5 ± NR				UWT/NWT: 39 (55%) OWT/Obese: 31 (45%)
		Control (n = 85)	7–12, 8.0 ± NR				UWT/NWT: 65 (77%) OWT/Obese: 20 (23%)
		P value					NR
10	Hammouda et al, 2018^Citation31	ASD (n = 30)	2–10, 4.9 ± 1.7				UWT: 7 (23.3%) NWT: 19 (63.3%) OWT: 0 (0.0%) Obese: 4 (13.3%)
		Control (n = 36)	2–10, 4.9 ± 1.7				UWT: 3 (8.3%) NWT: 31 (86.1%) OWT: 0 (0.0%) Obese: 2 (5.6%)
		P value	0.884				0.098
11	Ashour et al, 2018^Citation32	ASD (n = 41)	6–17				UWT: 2 (4.8%) NWT: 23 (56.1%) OWT: 7 (17.1%) Obese: 9 (21.9%)
		DS (n = 52)	6–17				UWT: 3 (5.7%) NWT: 24 (46.1%) OWT: 13 (25%) Obese: 12 (23.07%)
		CP (n = 17)	6–17				UWT: 2 (11.7%) NWT: 9 (52.9%) OWT: 3 (17.6%) Obese: 3 (17.6%)
12	Al-Blowi et al, 2020^Citation33	CP (n = 119)	5.9 ± 3.9				UWT: 101 (84.9%) NWT: 15 (12.6%) OWT: 3 (2.5%) Obese: 0 (0.0%)
13	Kasnawi & Jambi, 2020^Citation34	ASD (n = 32)	6–12, 8.0 ± 2.3			15.9 ± 3.2	UWT: 9 (28.1%) NWT: 20 (62.5%) OWT: 1 (3.1%) Obese: 2 (6.2%)
14	Mohamed et al, 2021^Citation35	ASD (n = 107)	6–12				UWT: 5 (4.7%) NWT: 49 (45.8%) OWT: 15 (14%) Obese: 38 (35.5%)
		DS (n = 70)	6–12				UWT: 2 (2.9%) NWT: 42 (60%) OWT: 15 (21.4%) Obese: 11 (15.7%)
		CP (n = 43)	6–12				UWT: 3 (7%) NWT: 22 (51.2%) OWT: 3 (7%) Obese: 15 (34.8%)
		ID (n = 123)	6–12				UWT: 7 (5.7%) NWT: 59 (47.9%) OWT: 32 (26.1%) Obese: 25 (20.3%)
		P value					NR
15	Almuneef et al, 2019^Citation36	CP (n = 74)	1–12, 5.6 ± 2.7					Weight-for-age-z-score (WAZ): −1.73 ± 1.02 Underweight (%):28.4% Height-for-age-z-score (HAZ): −1.30 ± 1.06 Stunting (%): 33.8% Weight-for-height-z-score (WHZ): −2.17 ± 1.30 Wasting (%): 25% BMI-for-age-z-score (BAZ): −1.68 ± 1.36 Thinness (%): 50% Malnutrition (%): 55.4%

Notes: *ASD: Autism Spectrum Disorder; DS: Down Syndrome; CP: Cerebral Palsy; ID: Intellectual Disability; NR: Not Reported; M: Male; F: Female; UWT: Underweight; NWT: Normal weight; OWT: Overweight.

‡Height information was not available for 5 healthy siblings, therefore, BMI and BMI-for-age for siblings are calculated for n=12.

Table 4 Laboratory Results Reported in the Selected Studies That Included in the Systematic Review (n = 12)

No.	Studies (First Author, Year)	Type of Cases*	Age (years) range, mean ± SD	Serum Vitamins mean ± SD /median (IQR)	Vitamin D Status n (%)	Serum Minerals (mmol/L) mean ± SD	Serum Fatty Acid (mmol/L) mean ± SD /median (IQR)	Serum Fatty Acid ratios	Hematological indices
1	Almuneef et al, 2019^Citation36	CP (n = 74)	1–12, 5.6 ± 2.7						Anemia/ Hemoglobin abnormal range % (57%); Hematocrit abnormal range % (34%); RBC abnormal range % (30%)
2	Elshorbagy et al, 2018^Citation37	ADHD (n = 50)	7–14, 9.31 ± 2.60	Calcitriol (ng/mL): 7.23 ± 8.98
		Control (n = 40)	6–13, 8.80 ± 3.72	Calcitriol (ng/mL): 31.47 ± 14.42
		P value	0.4	0.0009
3	El-Ansary et al, 2018^Citation38	ASD (n = 28)	3–12, 7.0 ± 2.34	Calcidiol (ng/mL): 95.63 ± 26.63
		Control (n = 27)	3–12, 7.2 ± 2.14	Calcidiol (ng/mL): 140.43 ± 17.68
		P value		0.001
4	Mostafa & AL-Ayadhi, 2012 ‡^Citation39	ASD (n = 50)	5–12, 8.24 ± 2.37	Vitamin D (ng/mL): 18.5^Citation14	Deficiency: 40% Insufficiency: 48% Sufficiency: 12%
		Control (n = 30)	5–12, 8.63± 2.65	Vitamin D (ng/mL): 33^Citation11	Deficiency: 0% Insufficiency: 20%, Sufficiency: 80%
		P value		< 0.001
5	Al-Gadani et al, 2009^Citation40	ASD (n = 30)	3–15	Vitamin E (mg/dL): 0.64 ± 0.39 Vitamin C (mg/dL): 6.88 ± 2.16
		Control (n = 30)	3–15	Vitamin E (mg/dL): 1.86 ± 0.47 Vitamin C (mg/dL): 7.70 ± 1.97
		P value		Vitamin E: ˂ 0.05 Vitamin C: > 0.05
6	Azhari, 2023 ‡‡^Citation41	ASD (n = 11)	4–12	Vitamin D (nmol/L): 29.43 ± 7.82	Severe Deficiency: 36% Deficiency: 46% Insufficiency: 0% Sufficiency: 18%
7	El-Ansary et al, 2011a^Citation42	ASD (n = 26)	4–12				Acetic acid: 0.972 ± 0.247 Valeric acid: 0.510 ± 0.229 Hexanoic acid: 1.442 ± 0.349 Stearidonic acid: 0.455 ± 0.120 Propionic acid: 0.874 ± 0.249 Butyric acid: 0.587 ± 0.267 Caprylic acid: 1.109 ± 0.281 Decanoic acid: 0.759 ± 0.182 Lauric acid: 0.808 ± 0.160 Palmitic acid: 1.631 ± 0.372 Stearic acid: 0.687 ± 0.281 Arachidic acid: 0.425 ± 0.222 a-Linolenic acid: 0.299 ± 0.067 Eicosapentaenoic acid: 0.284 ± 0.145 Docosahexaenoic acid: 0.380 ± 0.097 Linoleic acid: 0.220 ± 0.255 g-Linolenic acid: 0.162 ± 0.101 Arachidonic acid: 0.120 ± 0.040 Oleic acid: 0.225 ± 0.064 Elaidic acid: 0.122 ± 0.099
		Control (n = 26)	4–11				Acetic acid: 0.558 ± 0.082 Valeric acid: 0.100 ± 0.015 Hexanoic acid: 0.597 ± 0.478 Stearidonic acid: 0.363 ± 0.122 Propionic acid: 1.674 ± 0.441 Butyric acid: 0.738 ± 0.211 Caprylic acid: 2.250 ± 0.481 Decanoic acid: 1.954 ± 0.750 Lauric acid: 1.903 ± 0.574 Palmitic acid: 1.905 ± 0.537 Stearic acid: 1.219 ± 0.315 Arachidic acid: 0.673 ± 0.174 a-Linolenic acid: 0.354 ± 0.119 Eicosapentaenoic acid: 0.328 ± 0.112 Docosahexaenoic acid: 0.754 ± 0.340 Linoleic acid: 0.359 ± 0.162 g-Linolenic acid: 0.716 ± 0.323 Arachidonic acid: 0.574 ± 0.202 Oleic acid: 1.212 ± 0.518 Elaidic acid: 0.234 ± 0.080
		P value					Acetic acid: 0.0001 Valeric acid: 0.0001 Hexanoic acid: 0.0001 Stearidonic acid: 0.009 Propionic acid: 0.0001 Butyric acid: 0.028 Caprylic acid: 0.0001 Decanoic acid: 0.0001 Lauric acid: 0.0001 Palmitic acid: 0.037 Stearic acid: 0.0001 Arachidic acid: 0.0001 a-Linolenic acid: 0.045 Eicosapentaenoic acid: 0.245 Docosahexaenoic acid: 0.0001 Linoleic acid: 0.023 g-Linolenic acid: 0.0001 Arachidonic acid: 0.0001 Oleic acid: 0.0001 Elaidic acid: 0.0001
8	El-Ansary et al, 2010^Citation43	ASD (n = 30)	3–15			Calcium: 4.84 ± 1.25 Potassium: 8.55 ± 5.76 Sodium: 105.76 ± 17.75 Magnesium: 2.04 ± 0.49 Lead: 0.09 ± 0.04
		Control (n = 30)	3–15			Calcium: 11.67 ± 2.04 Potassium: 4.99 ± 2.12 Sodium: 118.11 ± 23.77 Magnesium: 1.83 ± 0.34 Lead: 0.03 ± 0.02
		P value				Calcium: ˂ 0.05 Potassium: ˂ 0.05 Sodium: > 0.05 Magnesium: > 0.05 Lead: ˂ 0.05
9	El-Ansary et al, 2011c^Citation44	ASD (n = 25)	4–12			Calcium: 4.42 ± 0.87 Potassium: 10.95 ± 5.26 Sodium: 105.06 ± 17.43 Magnesium: 1.97 ± 0.43
		Control (n = 16)	4–11			Calcium: 12.29 ± 1.53 Potassium: 4.76 ± 2.04 Sodium: 120.92 ± 21.94 Magnesium: 1.86 ± 0.35
		P value				Calcium: ˂ 0.05 Potassium: ˂ 0.05 Sodium: 0.036 Magnesium: 0.411
10	El-Ansary, 2017^Citation45	ASD (n = 35)	3–12, 7.0 ± 2.34			Lead (μg/dL): 6.04 ± 1.11 Selenium (μg/L): 111.9 ± 15.1 Mercury (μg/L): 3.66 ± 1.13
		Control (n = 30)	3–12, 7.2 ± 2.14			Lead (μg/dL): 3.89 ± 0.88 Selenium (μg/L): 194.6 ± 26.7 Mercury (μg/L): 2.71 ± 0.57
						Lead (μg/dL): < 0.001 Selenium (μg/L): < 0.001 Mercury (μg/L): < 0.001
11	Mostafa & AL-Ayadhi, 2015^Citation46	ASD (n = 100)	3–10, 6.22 ± 2.1				Docosahexaenoic acid (ω3) (μg/mL): 0.18 (1.2) Linolenic acid (μg/mL): 1.6 (1.3) Arachidonic acid (ω6) (μg/mL): 1.7 (1.8) Linoleic acid (μg/mL): 1.3 (2.6)	ω6/ω3: 3 (2.4)
		Control (n = 100)	3–10, 5.96 ± 2				Docosahexaenoic acid (ω3) (μg/mL): 3.1 (0.8) Linolenic acid (μg/mL): 3.3 (2.6) Arachidonic acid (ω6) (μg/mL): 4.2 (3.4) Linoleic acid (μg/mL): 3.2 (1.5)	ω6/ω3: 1.8 (1.4)
		P value					Docosahexaenoic acid (ω3) (μg/mL): < 0.001 Linolenic acid (μg/mL): < 0.01 Arachidonic acid (ω6) (μg/mL): < 0.01 linoleic acid (μg/mL): < 0.05	ω6/ω3: < 0.01
12	El-Ansary et al 2011b ‡‡‡^Citation47	ASD (n = 25)	4–12					LA/AA ratio: 1.08 ± 0.90 ALA/DHA ratio: 0.84 ± 0.19 AA/DHA ratio: 0.33 ± 0.14 EPA/DHA ratio: 0.61 ± 0.19 EPA/AA ratio: 0.96 ± 0.20
		Control (n = 16)	4–11					LA/AA ratio: 0.62 ± 0.16 ALA/DHA ratio: 0.59 ± 0.36 AA/DHA ratio: 0.81 ± 0.17 EPA/DHA ratio: 0.56 ± 0.39 EPA/AA ratio: 0.66 ± 0.37
		P value						LA/AA ratio: 0.034 ALA/DHA ratio: 0.004 AA/DHA ratio: 0.0001 EPA/DHA ratio: 0.576 EPA/AA ratio: 0.0001

Notes: * ASD: Autism Spectrum Disorder; CP: Cerebral Palsy; ADHD: Attention Deficit Hyperactivity Disorder. ‡ Vitamin D Status (deficiency: <10 ng/mL, insufficiency: 10 to 30 ng/mL, sufficiency: >30 ng/mL). ‡‡ Vitamin D Status (severe deficient: ˂24 nmol/L, deficient: 25–49 nmol/L, insufficient: 50–79 nmol/L, sufficient: >80 nmol/L). ‡‡‡ Linoleic acid/arachidonic acid (LA/AA) ratio; a-linolenic acid/docosahexaenoic acid (ALA/DHA) ratio; arachidonic acid/docosahexaenoic acid (AA/DHA) ratio; Eicosapentaenoic acid/docosahexaenoic acid (EPA/DHA) ratio; Eicosapentaenoic acid/arachidonic acid (EPA/AA) ratio.

Table 5 Dietary Intake Results Reported in the Selected Studies Included in the Systematic Review (n = 4)

No.

Studies (First Author, Year)

Type of Cases*

Age (years) range, mean ± SD

Energy (kcal/day)

Carbohydrates (g/day)

Protein (g/day)

Fat (g/day)

Fiber (g/day)

Omega-3 Fat (g/day)

Vitamin A (ug/day)

Carotene (ug/day)

Vitamin D (ug/day)

Vitamin E (mg/day)

Vitamin C (mg/day)

Thiamin (mg/day)

1

Samarkandy et al, 2012^Citation29

DS (n = 108)

5–12

1692 ± 442

246.5 ± 68.2

55 ± 14

53.4 ± 14.8

11.65 ± 4.7

543.5 ± 225.4

894.5 ± 328

50.2 ± 32.4

0.7 ± 0.35

Control (n = 113)

5–12

1826 ± 562

245.5 ± 88

65.6 ± 23

64.7 ± 29

12.45 ± 5.7

719 ± 387

841.5 ± 415

56 ± 28

0.8 ± 0.3

P value

0.21

0.84

<0.001

0.031

0.57

0.024

0.73

0.72

0.71

2

Alahmari et al, 2022^Citation30

ASD (n = 70)

7–12, 8.5 ± NR

1522 ± 269

160 mg/d

22.2

0.27

Control (n = 85)

7–12, 8.0 ± NR

1311 ± 132

0 mg/d

0

0

P value

0.01

≥0.05

<0.05

≥0.05

3

Hammouda et al, 2018^Citation31

ASD (n = 30)

2–10, 4.9 ± 1.7

1330 ± 541

199 ± 87

38 ± 20

46 ± 24

0.029 ± 0.036

1.31 ± 1.91

Control (n = 36)

2–10, 4.9 ± 1.7

1576 ± 463

234 ± 67

48 ± 25

54 ± 21

0.268 ± 0.498

1.60 ± 1.60

P value

0.884

0.051

0.076

0.091

0.159

0.011

0.515

4

Kasnawi & Jambi, 2020^Citation34

ASD (n = 32)

6–12, 8.0 ± 2.3

209 ± 89.03

49.64 ± 20.73

12.81 ± 7.92

2.30 μg/d ± 127.14

2.12 μg/d ± 1.90

4.08 mg/d ± 2.27

85.4 mg/d ± 64.01

No.

Studies (First Author, Year)

Type of Cases*

Age (years) range, mean ± SD

Riboflavin (mg/day)

Vitamin B6 (mg/day)

Folic acid (mg/day)

Vitamin B12 (mg/day)

Sodium (mg/day)

Potassium (mg/day)

Calcium (mg/day)

Phosphorus (mg/day)

Iron (mg/day)

Magnesium (mg/day)

Selenium (mg/day)

Zinc (mg/day)

1

Samarkandy et al, 2012^Citation29

DS (n = 108)

5–12

1.5 ± 0.74

1880 ± 675

1704 ± 535

515 ± 297

911 ± 327.5

25 ± 3

Control (n = 113)

5–12

1.8 ± 0.85

2331 ± 767

1964 ± 751

626 ± 277.3

1029 ± 277.4

33 ± 4

P value

0.032

<0.001

0.038

0.017

0.21

0.34

2

Alahmari et al, 2022^Citation30

ASD (n = 70)

7–12, 8.5 ± NR

0

0

169

0.38

1444

1454

466

468

8

84

7

4

Control (n = 85)

7–12, 8.0 ± NR

0

0

270

0.83

2071

1320

820

463

14

150

8

4

P value

≥0.05

≥0.05

<0.05

<0.05

<0.05

<0.05

<0.05

≥0.05

<0.05

<0.05

<0.05

≥0.05

3

Hammouda et al, 2018^Citation31

ASD (n = 30)

2–10, 4.9 ± 1.7

173 ± 128 μg/day

0.45 ± 2.27 μg/day

538 ± 332

6.66 ± 4.00

Control (n = 36)

2–10, 4.9 ± 1.7

203 ± 97.9 μg/day

0.55 ± 1.9 μg/day

331 ± 560

10.23 ± 6.01

P value

0.884

0.44

0.365

0.797

0.007

4

Kasnawi & Jambi, 2020^Citation34

ASD (n = 32)

6–12, 8.0 ± 2.3

1.77 μg/d ± 83.67

1.75 μg/d ± 1.24

533 mg/d ± 365.67

8.57 mg/d ± 3.98

3.79 mg/d ± 1.86

Notes: *ASD: Autism Spectrum Disorder; DS: Down Syndrome; NR: Not Reported.

Table 6 Types of Collected Data Related to Dietary Behavior Included in the Systematic Review (n = 10)

No.	Studies (First Author, Year)	Type of Cases*	Age (years) range, mean ± SD	Meals Intake	Healthy Foods Intake	Unhealthy Foods Intake	Mealtime Behavior	Feeding Difficulties
1	Mohamed et al, 2013^Citation27	DS	5–12		Meat Chicken Fish Egg Whole milk Low-fat/skimmed milk Cheese Rice/macaroni Fresh vegetables Fresh fruits	Fast food	Difficulties in using utensils Food rejection Eating meals with the family	Vomiting after meals Chewing/swallowing difficulties
2	Bindayel, 2021^Citation28	DS	3–18	Breakfast Lunch Dinner	Dairy Products Seafood Red Meat Fruits Vegetables/salad Rice Caffeinated beverages	Fast food Dessert/Sweets Carbonated beverages
3	Hammouda et al, 2018^Citation31	ASD	2–10		Milk Dairy products Eggs Fresh fruits Cooked vegetables Fresh vegetables Tuna Other fish types Liver Meat Include (chicken) Butter Olive oil	Fast food Sweets Sweetened Juice Soft drinks Processed meat
4	Kasnawi & Jambi, 2020^Citation34	ASD	6–12		Milk & cheese Fat & sauces Fruit Legumes & pasta Meat & eggs Vegetables Cereal, bread and rice Beverages	Snacks & sweets
5	Almuneef et al, 2019^Citation36	CP	1–12					Feeding problems Appetite of child
6	AlOmar et al, 2021^Citation48	ASD	3–10	Regular meals	Milk intake Fish and egg intake Fruits intake
7	Bin Ammar & Almuhaini, 2022^Citation49	ASD	4–12				Cries or screams at mealtimes Turns his/her face or body away from food Expels food that he/she has eaten Remains seated at the table until the meal is finished Aggressive during mealtimes Displays self-injurious behavior during mealtimes Closes mouth tightly when food is presented Is disruptive during mealtimes Is flexible about mealtime routines Is willing to try new foods Prefers the same food for each meal Prefers crunchy foods Accepts or prefers a variety of foods Prefers to have food served in a particular way Prefers food prepared in a certain way (Fried and greasy) Prefers only sweet foods Dislikes certain foods and will not eat them Refuses to eat foods that require a lot of chewing
8	Bin Eid et al, 2022^Citation50	ASD	5–12	No. snacks/day No. meals/day
9	Murshid, 2014^Citation51	ASD	3–14	Snacks per day		Sweet food per day Soft drinks per day	Prefers sweet food
10	Al-Hammad, 2015^Citation52	CP	2–10	Frequency of main meals	Meats Vegetables Fruits Bottled Water Tap Water Fresh Fruit Juice Cheese	Puddings Packed Juices Soft Drinks Flavored Fizzy Drinks Biscuits Potato Chips Chocolates

Notes: * ASD: Autism Spectrum Disorder; DS: Down Syndrome; CP: Cerebral Palsy.

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