Extreme picky eating, or ARFID, is an eating disorder that has very real consequences for health and well-being. Dietitian Brad Brosnan explains.
Do you know a picky eater? Are you one yourself?
Avoiding certain foods because of their taste, smell or texture is something we all do at different stages in our lives.
Getting kids to try new foods can be challenging for parents and being fussy at mealtimes is a common phase of growing up.
Picky eating is nothing new, but what happens if eating becomes scary? When taken to an extreme, picky eating can, in fact, be an eating disorder called ARFID (avoidant/restrictive food intake disorder).
What is ARFID?
Classified as a mental disorder in 2013 by the American Psychiatric Association, ARFID is a relatively new diagnosis. Those with the disorder can have severe food aversions resulting in reduced appetite that may leave them unable to meet their nutritional needs. Although ARFID is typically diagnosed in children and adolescents, it can affect people of all ages.
The condition varies in severity from person to person but, in general, people with ARFID tend to avoid whole food groups, such as fruit and vegetables, dairy products or most meat. They commonly stick to a small list of foods that are nutritionally poor, very dry and mostly beige coloured, such as chips, chicken nuggets and white bread. While picky eaters tend to avoid certain foods, they’re still able to meet their nutritional needs, but this isn’t the case with ARFID. Those with the disorder don’t get the necessary kilojoules or nutrients.
In children, this can lead to stunted growth and adults can suffer from low energy and weight loss. ARFID can also impair social relationships and cause problems at school or work. Many sufferers have problems socialising, eating out and, sometimes, need much more time to eat.
It can be difficult to distinguish between picky eating and ARFID, particularly in children. Take, for example, telling a child to ‘eat the food, or go to bed hungry’.
Strategies like this may work with picky eaters but would never work for anyone with ARFID. This is because ARFID sufferers aren’t just being stubborn, they’re often fearful of specific food colours, textures, tastes or smells. Forcing someone with ARFID to eat what’s in front of them may cause them to vomit, leading to a traumatic experience, which could worsen the problem.
What causes ARFID?
Because ARFID is still a relatively new diagnosis, research is still being done to identify how it develops and why.
Despite this, health professionals and researchers can agree that ARFID is the result of a combination of several different factors, such as psychosocial components, genetics and environmental influences.
Most people are familiar with eating disorders such as anorexia or bulimia. Both of these disorders tend to involve a fear of weight gain and distorted body image, but this isn’t the case with ARFID. Commonly, ARFID develops from a sensory dysregulation that causes the person to become hypersensitive to textures, smells, noises and appearances.
There are a number of other factors that can contribute to the development of ARFID such as pain, discomfort or a traumatic choking or vomiting incident. From that point forward, eating related ‘fear’ foods can be scary or uncomfortable.
Parents of children with ARFID commonly feel guilt, self-blame and anxiety, which is understandable, but it’s important for parents to overcome these feelings by focusing on understanding the disorder and learning strategies to help and support their child.
ARFID signs and symptoms:
- Avoidance of foods based on texture, colour, taste, smell, food groups, etc
- Anxiety when presented with ‘fear’ foods
- For adults, weight loss.
- For children, failure to gain weight
- Frequent vomiting or gagging after exposure to ‘fear’ foods
- Difficulty chewing food
- Lack of appetite
- Eating extremely small portions
- Social isolation, particularly around meal times.
How is ARFID diagnosed?
To be diagnosed as having ARFID, a person will constantly struggle to meet their nutritional and/or energy needs, affecting one or more of the following:
- Significant weight loss (or stunted growth in children)
- Significant nutritional deficiency
- Dependence on nutritional supplements
- Noticeable difficulties socialising.
People with autism spectrum disorder, anxiety or sensory dysregulation may also experience similar eating difficulties, but ARFID is only diagnosed if their eating habits or food avoidance is beyond what would be expected from their current diagnosis. While ARFID is more often diagnosed in children and adolescents, it does occur in adults. These cases usually stem from untreated childhood symptoms and a prolonged pattern of selective eating from fear of trying new foods.
If you or a loved one is experiencing or showing behaviours like the ones above, start by talking to your doctor. Keep in mind that some people with ARFID can appear healthy, or even overweight, but they may suffer from other unseen deficiencies.
Health risks associated with ARFID:
- Developmental delays
- Anorexia nervosa
- Gastrointestinal complications
- Anxiety and depression
- Difficulty at school or work.
How is ARFID treated?
It’s important to seek professional help to treat ARFID. This help can include dietitians, doctors or paediatricians, psychologists and occupational therapists. Everyone diagnosed can have different ‘fear’ foods, so the treatments tend to vary from person to person. With individualised treatment, clinicians work with patients and family members in numerous ways to increase their flexibility with ‘fear’ foods and widen the range of what they eat to satisfy nutritional needs and counter weight loss.
There are three specialist eating disorder services in New Zealand, located in Auckland, Wellington and Christchurch. ARFID can also be treated through paediatric feeding clinics throughout New Zealand and some private treatment providers are also available.
Take home message
Despite the extremes and complexities of ARFID, it is a treatable condition. It presents differently from one person to the next, so there isn’t one standard treatment. To help identify whether someone has the condition, look for signs that food has become scary and is compromising well-being. Public funding in New Zealand is limited, but if you believe it’s more than just picky eating, it’s important to seek further input from your GP and seek a professional who is experienced in eating disorders.
Tips for people with ARFID
- Avoid losing any current ‘safe’ foods. To accomplish this, try not to have the same food in the same way two days in a row, by making just a very small change in the appearance, texture or taste.
- Maximise nutrition of current ‘safe’ foods. Start looking at labels to find more nutritious products.
- Increased iron and fibre can be found in some breads and some cereals can be fortified with iron, B vitamins and calcium. Multi-vitamin chewables can be an option for those that can tolerate the flavour.
- When introducing new foods, look for options similar to what’s ‘safe’ and slowly branch out from there. For example, eat raw apples then try dried apples.
Tips for better meal times from ARFID parents
- Create a safe and calm environment when eating and avoid applying pressure.
- Use positive language such as ‘food explorer’.
- Structure regular meal and snack times.
- Sometimes distractions such as games or conversations can take the pressure off meal times.
- Use an age-appropriate seat that supports the posture and is non-slip.
- Eat as a family, regularly. Meal supervision is key to recovery and eating together creates opportunities for bonding and good role modelling.
- One attempt is not enough. Be persistent and consistent in empathetically helping your child practise eating new foods.
- Celebrate small achievements and attempts. Your encouragement helps build confidence.
Sources and References
- American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington DC: American Psychiatric Association
- Dent E. 2017. Anorexia of aging and avoidant/restrictive food intake disorder. Journal of the American Medical Directors Association 18:449-50
- Dietitians of Canada. 2014. Tips on Feeding Your Picky Toddler or Preschooler, dietitians.cahttps://www.dietitians.ca/Downloads/Factsheets/Tips-Feeding-Picky-Toddler.aspx
- Fisher MM et al. 2014. Characteristics of avoidant/ restrictive food intake disorder in children and adolescents: A ‘new disorder’ in DSM-5. Journal of Adolescent Health 55:49-52
- Kennedy GA et al. 2018. Eating disorders in children: Is avoidant-restrictive food intake disorder a feeding disorder or an eating disorder and what are the implications for treatment? F1000Research 7:88
- Norris ML et al. 2016. Update on eating disorders: Current perspectives on avoidant/restrictive food intake disorder in children and youth. Neuropsychiatric Disease and Treatment 12:213-8
- Sharp WG et al. 2017. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: How standard is the standard of care? Journal of Pediatrics 181:116-24 e4
- Thomas JJ et al. 2017. Avoidant/restrictive food intake disorder: A threedimensional model of neurobiology with implications for etiology and treatment. Current Psychiatry Reports 19:54
- Trofholz AC et al. 2017. How parents describe picky eating and its impact on family meals: A qualitative analysis. Appetite 110:36-43
- Zickgraf HF et al. 2016. Adult picky eaters with symptoms of avoidant/ restrictive food intake disorder: Comparable distress and comorbidity but different eating behaviors compared to those with disordered eating symptoms. Journal of Eating Disorders 4:26