Nutritional epigenetics education improves diet and attitude of parents of children with autism or attention deficit/hyperactivity disorder

Table 1 Content of each module of instruction

Module	Title/book chapter	Topics covered	Activities	Films
One	How food regulates and supports gene function	Genes, epigenetics, gene regulation, methylation, hypomethylation, methyl donating nutrients, micronutrients to support PON1, BDNF, and MT	3	Ghost in your genes (BBC television)
Two	What we eat or don’t eat leads to disease	Characteristics of SAD, obesity, malnutrition, nutritional deficits, gene malfunction, USDA food availability system, refined sugar and vegetable oil consumption trends	3	Super size me (streaming documentary)
Three	Ingredients that add heavy metals to your body	Allowable heavy metal levels in food ingredients (e.g., food coloring, preservatives), food manufacturing, chlor-alkali refining, known contaminants (e.g., vegetable oils), zinc deficiency in autism and ADHD	4	The medicine of food (Smithsonian Institute)
Four	What we know about corn sweeteners	Corn sweeteners, manufacturing process, contamination, ultra-processed foods, heavy metal bioaccumulation, western diet - > western disease	2	King corn (streaming)
Five	What we know about pesticides	Chlorine, USDA Pesticide Data Program, OP, PON1 gene function in autism/ADHD, symptoms of OP poisoning	3	The autism revolution: Thinking about environment and food (IATP)
Six	How we can create a safe food environment	Current food regulations (e.g., ingredient safety and labeling), history of FDA, food allergies, dietary supplements, Hg in fish issues, healthy food labels	4	No video

ADHD: Attention deficit hyperactivity/disorder; OP: Organophosphate; PON-1: Paraoxonase-1; MT: Metallothionein; FDA: Food and Drug Administration; IATP: Institute for Agriculture and Trade Policy.

Table 2 Change in diet scores for each participant (for sample size calculation)

	Intervention	Control	P value (t-test)
N	10	10
Mean diet score
Baseline	16.0 (2.83)	16
6 wk	23.2 (1.72)	16
Change	7.2	0	< 0.05

Data are means with SD and t-test.

Table 3 Changes in intake of ultra-processed food pre- and post-intervention

Survey questions (questions begin with “During the past month, how many times did you …?”	Pre-intervention		Post-intervention
	Test	Control	Test	Control
…drink a sugar sweetened beverage such as ginger ale, orange soda, fruit punch, root beer, or other soft drink (do not include diet drinks)1	5	8	9	8
…eat canned fruit with syrup or added sugar (applesauce, apricot halves, mixed fruit, pears, cling peaches)?1	9	8	11	10
…eat canned meals (soup, re-fried beans, chili, spaghetti, beef stew, etc.…)?2	8	10	10	11
…eat processed cheese (American, yellow cheddar)?1	3	5	9	6
…eat sweetened or flavored milk products (fruity or sweetened yogurt, pudding cups, chocolate flavored milk, etc.…)?1	8	7	9	7
…eat processed meat (lunch meat, hotdogs, bacon, ham in a can, sausage, beef jerky, etc.)?2	4	7	10	8
…eat ready to eat cereal (corn flakes, rice crisp, corn squares, fruity o’s, oat circles, etc.)?2	3	5	7	3
…eat swordfish or tuna (canned, fresh, or frozen)?1	8	7	9	7
…eat foods fried in vegetable oil such as potato or corn chips, popcorn, French fries, hash browns, fry bread, fast food fried chicken, fish sticks, doughnuts?2	5	6	10	5
…eat food purchased from a drive thru taco or hamburger restaurant, pizza parlor, other chain?1	4	5	9	7
…eat sweet snacks such as candy, cookies, ice cream, popsicle, other sugar sweetened treat (do not include diet)?2	1	6	8	8
…eat grain products made of wheat such as macaroni, bread, hamburger or hotdog buns, or spaghetti?2	4	3	4	2
…eat white rice?2	8	9	8	10
Total diet score	70	86	113	92
mean ± SD	5.385 ± 2.534	6.615 ± 1.895	8.692 ± 1.750	7.077 ± 2.629

¹Score = 1 if “never, rarely (once or twice a month)”.

²Score = 1 if “never, rarely, once a week”.

Table 4 Changes in intake of whole and/or organic food pre- and post-intervention

Survey questions (questions begin with “During the past month, how many times did you …?”	Pre-intervention		Post-intervention
	Test	Control	Test	Control
…eat crab or oyster (fresh, frozen, or canned)?1	4	2	6	1
…drink unflavored milk (non-fat, 2%, or whole)?2	7	5	7	4
…eat product made from unsweetened, unflavored milk (plain yogurt, cottage cheese, white cheese)?3	9	9	10	8
….eat fresh or frozen fruit (bananas, oranges, apples, strawberries, blueberries, etc.)?2	10	10	10	10
…eat canned vegetables (spinach, green beans, corn, peas, mixed vegetables, tomato, etc.)?4	5	5	2	4
…eat frozen vegetables (spinach, green beans, corn, peas, carrots, mixed vegetables, etc.)?2	3	5	3	3
…drink 100% fruit or vegetable juice (apple, orange, grape, tomato, etc.)?3	4	5	6	6
…eat salmon or sardines (frozen, fresh or canned)?3	3	1	4	1
…eat poultry (chicken or turkey)?2	9	7	8	9
…eat red meat (hamburger, beef, pork, lamb, etc.)?3	10	10	8	10
…eat nuts or seeds (Brazil, sunflower, pine, almonds, sesame seeds, peanuts, pecans)?3	4	6	6	5
…eat dark green vegetables (romaine lettuce, spinach, broccoli, kale, Swiss chard, collard or other greens)?2	7	5	7	3
….eat brown rice?1	7	5	9	6
…eat oatmeal?1	6	8	8	7
….eat foods prepared with organic flour?1	4	3	9	4
…eat organic produce?1	5	10	10	10
….eat organic processed foods (bread, cereal, etc.)?1	3	9	8	10
Total diet score	100	105	121	101
mean	5.88	6.176	7.12	5.941
SD	2.47	2.811	2.39	3.152

¹Score = 1 if “rarely (once or twice a month), once a week, several times a week, pretty much every day (1-2 servings)”.

²Score = 1 if “several times a week, pretty much every day (1-2 servings), several times a day (3 or more servings)”[45].

³Score = 1 if “once a week, several times a week, pretty much every day (1-2 servings)”.

⁴Score = 1 if “once a week, rarely (once or twice a month)”.

Table 5 Characteristics of participants in nutritional epigenetics tutorial study

	Test group, n = 11	Control group, n = 11
Race or ethnic group (%)
White - not Hispanic	7 (63.6)	8 (72.7)
Black or African American	1 (9.1)
Asian	3 (27.3)	1 (9.1)
Mixed - more than one race		2 (18.2)
Educational level of parent (%)
High school diploma or GED
Some college or college degree	11 (100)	11 (100)
Age of learning-disabled child (%)
34 mo - 4 yr of age	2 (18.2)	2 (18.2)
5-6 yr of age	3 (27.3)	3 (27.3)
7-8 yr of age	6 (54.5)	6 (54.5)
Problem child behaviors observed by parent in the last 24 h (%)
Tantrum	7 (63.6)	5 (45.4)
Hyperactivity	9 (81.8)	7 (63.6)
Self-injury (head banging)		2 (18.2)
Pica (chewing on objects)	5 (45.4)	5 (45.4)
Aggression (name calling, hitting)	4 (36.4)	2 (18.2)
Running away	5 (45.4)	4 (36.4)

Data are frequency (%).

Table 6 Changes in parent dietary intake within groups pre- vs post-intervention

Food category	Pre vs post-intervention		Paired sample t-test	Pre vs post-intervention		Paired sample t-test
	Test (n = 11)	Test (n = 11)	P value	Control (n = 11)	Control (n = 11)	P value
Ultra-processed food
Total diet score	70	113		86	92
mean	5.385	8.692	0.0001	6.615	7.077	0.107
SD	2.534	1.750	< 0.001	1.895	2.629	> 0.05
Whole and/or organic food
Total diet score	100	121		105	101
mean	5.882	7.118	0.021	6.176	5.941	0.205
SD	2.472	2.390	< 0.05	2.395	3.152	> 0.05

Table 7 Within group summary with key findings of t-test results showing changes in parental dietary intake within groups pre- vs post-intervention

Ultra-processed food, test group, pre vs post	Ultra-processed food, control group, pre vs post	Whole and/or organic food, test group, pre vs post	Whole and/or organic food, control group, pre vs post
P < 0.001	P > 0.05	P < 0.05	P > 0.05
t = -4.9109, df = 12	t = -1.3145, df = 12	t = -2.209, df = 16	t = 0.84563, df = 16
P-value = 0.0003592	P-value = 0.2132	P-value = 0.0421	P-value = 0.4102
Effect size = 1.36	Effect size = 0.36	Effect size = 0.54	Effect size = 0.21
Cohen’s d - large	Cohen’s d - small	Cohen’s d - medium	Cohen’s d - small
H0: Mean pre-intervention group = mean post intervention group	H0: Mean pre-intervention group = mean post intervention group	H0: Mean pre-intervention group = mean post intervention group	H0: Mean pre-intervention group = mean post intervention group
H1: Mean pre intervention group ≠ mean of post intervention group	H1: Mean pre intervention group ≠ mean of post intervention group	H1: Mean pre intervention group ≠ mean of post intervention group	H1: Mean pre intervention group ≠ mean of post intervention group
H0 rejected	H0 supported	H0 rejected	H0 supported
Significant difference between pre and post intervention for test group. Mean of test group was greater than the mean of the control group	No significant difference between pre and post intervention for control group	Significant difference between pre and post intervention for test group. Mean of the test group was greater than the mean of the control group	No significant difference between pre and post intervention for control group

Table 8 Differences in attitude about behavioral control pre- and post-intervention

Survey question	Pre-intervention		Post-intervention
	Test (n = 11)	Control (n = 11)	Test (n = 11)	Control (n = 11)
To what extent do you agree with the following statement: “I have the ability to control the behavior of my family’s learning-disabled child through diet”?
Total score	3	4	10	3
mean	0.273	0.364	0.909	0.273
SD	0.467	0.505	0.302	0.467

Data were coded “1” if participant responded with “strongly agree” or “agree” and “0” for all other responses.

Table 9 Feedback from parents who completed online nutritional epigenetics tutorial

Survey questions	Feedback
Did you find the cupboard surveys and other activities helpful in preparing healthy meals for your family? Why or why not?	Yes. I’m trying to buy more organic foods after the tutorial. I was in denial before the tutorial
	Yes. Learned to pay attention to food ingredient labels
	Yes, it made me look at what I currently have and evaluate it. A lot of the items I had in my pantry I had no idea had some of the “toxic” ingredients. It made me look at it immediately instead of just thinking, “I’ll look at it later.”
	Yes, it is very helpful because I learned that I need to check the contents of the food before serving it to my family
	I thought it was a good way to really ‘see’ what you’ve been buying
	Yes! It forced me to take a difficult look at what I was feeding myself and my family. It’s one thing to understand a concept in a book, entirely different thing to see it in real time in your own kitchen and on your children’s dinner plates
	Yes, it makes you accountable for what is in your pantry
	Yes, the surveys/activities made me take the time to go through my food items and see how good/bad they were for my family
	Yes, the cupboard surveys were very helpful. The surveys allowed me to take an inventory of what I was feeding my family. It has also helped me be more aware of the food labels when purchasing food from the grocery store
	Yes. It made me really look at the things I was feeding my kids
What did you learn? How did the tutorial change you or your family’s diet?	I should purchase organic grains and avoid cereals. I’m considering purchasing a bread machine so that I can make my own organic bread
	We changed to an organic more Mediterranean type diet
	I learned specifically what toxic foods/ingredients are put into our foods and then what foods will help counteract the negative effects of them. It changed our diet by making me change not only what I take out of our diet (like as much HFCS as I can, and processed foods in general), but also what I can add to improve negative reactions (like how Brazil nuts have selenium)
	This helped me a lot especially when it comes to serving food to my child with autism. He’s a very picky eater but thank God he’s improving right now
	This really opened my eyes to things that should have been obvious but weren’t
	I learned so much! It has absolutely changed the way I buy and prepare foods. I’m also inspired to live more sustainably, growing and preserving our own foods
	As a family we have become more aware of what we eat and the ingredients in our food. We are trying to make more health choices, including not choosing flavored milk at school
	I learned that most processed/packaged food contains ingredients that are detrimental to our bodies, regardless of what the nutrition label says. Eating fresh-grown, organic produce and meats seems to be the only way to go
	I learned that the food available for consumption, although it may taste good, is not always good for us. The tutorial has taught me more about the dangers of certain food ingredients. As a result of the tutorial I have changed my family’s diet by serving less of those ingredients and in most cases eliminating many of them
	I learned a lot, and I have made modest changes along with changing my husband’s views, which is big

HFCS: High fructose corn syrup.