The sample of this cross-sectional study, which was conducted to determine the nutritional status and feeding behavior of children diagnosed with SLD, consisted of 76 children, 38 boys and 38 girls. Although there are serious difficulties in the diagnostic process due to the lack of SLD diagnosis and screening tools in Turkey, all children diagnosed with SLD start special education and 3% of the children receiving special education are those with SLD . Epidemiological studies on the relationship between SLD prevalence and gender reports that SLD is more common in boys than in girls [22–24]. In the special education center where the data of this study were collected, there are 112 children (boys 63, girls 49) between the ages of 7 and 12 who were diagnosed with SLD.
Breast milk, which is the ideal food for newborns and infants, is considered important for optimal brain development and better neurodevelopmental outcomes . According to the Population and Health Survey conducted in Turkey in 2018, the median breastfeeding period of infants was reported as 16.7 months, while 41.0% of children younger than six months were reported to be exclusively breastfed . It was found that 97.0% of the children with SLD who participated in this study were breastfed and the mean duration of breastfeeding was 15.40 ± 0.88 months.
It was determined that 43.4% of the children participating in this study received nutritional support and the most frequently used nutritional supplement was omega 3 (63.6%) fatty acids. It has been stated that some physical symptoms such as excessive thirst, frequent urination, dry hair and skin, soft and brittle nails may be caused by omega-3 fatty acid deficiency in individuals with dyslexia (80%-90%), which is the most common type of SLD . While these results indicate that omega-3 fatty acid supplementation may have positive effects in individuals with SLD, it was determined in a systematic review study that omega 3 supplementation did not have any positive effect on reading, writing, spelling, or math skills in individuals with SLD .
SLD is not usually seen alone, it shows comorbidity with many diseases. The most common comorbidities include ADHD, conduct disorder, psychosis, epilepsy, anxiety, and depression . When studies evaluating comorbidities in SLD were examined, it was reported that 41.9% ADHD , 34.0% attention deficit disorder, 22.0% ADHD , 45.1% ADHD . In this study, comorbidity was determined in 44.7% of the children according to the statements of the parents. Comorbidities include ADHD, epilepsy, bipolar disorder, asthma, diabetes, and ulcer, and the most common comorbidity is ADHD (79.5%), consistent with the literature.
Sensory processing problems that can be seen in neurodevelopmental disorders can cause inadequate response to foods, limit the variety of foods consumed and social enjoyment of food. Perceived sensory properties of foods affect food selectivity and rejection in children . In a study, the prevalence of nutritional problems in children aged 3–10 years with neurodevelopmental disorders was determined as 61%, and it was determined that food selectivity, food rejection, anger at meal and loss of appetite were among the common nutritional problems . In this study, it was determined that 78.8% of the children had nutritional problems and the most common ones were food selectivity (95.0%) and anorexia (16.7%).
Feeding behavior problems in children can be seen because of disturbing behavioral problems and changing appetite. This can lead to food selectivity and refusal to try new foods in children, leading to malnutrition . In a study, feeding behavior problems were determined in one-third of children (4–12 years old) with ADHD, and problematic behaviors were determined in 27.8% of them . As in other neurodevelopmental disorders, feeding behavior problems were found in 39.5% of children with SLD in this study. When parents were asked whether the statements about their children's feeding behavior were a problem for them, 17.1% reported that they created a problem. According to the results of this study, it is thought that the high number of feeding behavior problems in children and the appetite-reducing effects of stimulant drugs (81.9%) may pose a risk of malnutrition in children with SLD.
When the energy and nutrient intakes of the children with SLD were examined according to the feeding behavior problems, the average energy, carbohydrate, protein, fat, niacin, B12 and zinc intakes of the children with eating behavior problems were found to be lower than those of the children without feeding behavior problems, but the difference between only protein intake the difference was found to be statistically significant. When these results are evaluated, it is seen that nutritional behavior problems affect children's daily dietary energy and nutrient intakes. These results show that feeding behavior problems affect children's daily dietary energy and nutrient intakes. Considering both the negative effects of stimulant drugs on appetite and feeding behavior problems, appropriate screening tests are recommended to determine the nutritional status of children with SLD.
Although there is no study in the literature that evaluates anthropometric measurements in children with SLD, there are studies on ADHD, which is a comorbidity found in most children. In a study, children between the ages of 6 and 12 diagnosed with ADHD were classified according to their BMI percentile values, and it was found that 23% of the children were underweight and 25% were overweight. While the rate of the newly diagnosed children was 6.5%, it was found as 41.4% in the group using stimulant drugs . In the study by Kim and Chang  with a healthy control group of children diagnosed with ADHD at school age, children with ADHD were 6 cm shorter in height and 1.7 kg lower in body weight, and this difference was found to be statistically significant. Tayşi  reported that 50.8% of the children were at normal body weight, 18.5% were overweight and 13.0% were obese, in her study with participants (6–10 years old) diagnosed with ADHD. It was determined that 65.8% of the children included in this study had normal body weight according to the BMI Z score classification. The fact that the majority of children consume three main meals and snacks daily can explain their normal body weight according to BMI classification. Additionally, due to the pandemic, continuing education online and children's meals with their parents may have affected food consumption. However, in this study, it was not questioned how long the children had been using stimulant drugs. If there is a decrease in appetite in children who are new to or have been using stimulant drugs for a short time, this may not have affected anthropometric measurements yet.
In this study, the relationship between children's BMI, TMI, MUAC, TSFT and waist circumference and feeding behavior problems was found to be statistically significant. The lower the body weight, BMI, MUAC, TSFT and waist circumference in children with SLD, the more feeding behavior problems are seen. In a study, a negative correlation was found between body weight, height, BMI, and feeding behavior problems of children aged 4–12 years with ADHD, but this relationship was found to be statistically significant for body weight and BMI (p < 0.05) .
In the binary logistic regression analysis, it was determined that 1 cm increase in children's MUAC reduced feeding behavior problems by 0.606 times, and 1 cm increase in waist circumference increased eating behavior problems 1.172 times. While the MUAC is a measurement that evaluates the arm muscle and subcutaneous adipose tissue, the waist circumference indicates abdominal fatness . The fact that children with feeding behavior problems consume unhealthier foods (snacks and beverages, etc.), uniform nutrition, and insufficient physical activity may have caused this result. The presence of abdominal obesity in children with SLD indicates that there may be feeding behavior problems. Abdominal obesity in childhood can increase the risk of developing many diseases such as diabetes, dyslipidemia and hypertension in adulthood. For this reason, it is important to evaluate the waist circumference in children with SLD during health checks and to expand nutrition education in schools to prevent or reduce feeding behavior problems.