Know Someone Who Deserves a Picky Eater Award?

Do you find yourself scouring the juice aisle for pulp-free orange juice because the “pieces” drive your child crazy? Do they only eat “shiny” peas from the freezer because “dull” canned peas don’t taste right? Or maybe you’re racking up mileage on your car as you drive all over looking for a specific brand of yogurt?

You might think this is just super-powered picky eating, but it could be an eating disorder known as ARFID (avoidant/restrictive food intake disorder). Adolescent medicine expert Ellen Rome, MD, MPH, clarifies when picky eating goes too far.

What is ARFID?

“ARFID is an eating or feeding disturbance that includes food avoidance or a lack of interest in eating,” says Dr. Rome. “ARFID can mean an extreme form of picky eating that comes with nutritional deficiency, significant weight loss or, in children, failure to grow and gain weight.”

Nearly 5% of children have ARFID, and a higher percentage of boys experience it, as compared with anorexia nervosa and bulimia nervosa. It’s recognized more commonly in children and young teens than in older adolescents and adults. But it’s increasingly more common in adults thanks to diet trends that eliminate certain food groups from the diet (like gluten-free or vegan diets).

It’s important to note that ARFID is not associated with:

• Concerns over body image (in contrast to individuals with anorexia nervosa).
• Lack of available food.
• Avoiding certain foods because of cultural or religious reasons.
• Health disorders that, when treated, will resolve the eating concerns.

Picky eating differs from a selective eating disorder such as ARFID

If your child has ARFID, their response to food is beyond their control. They may know that they need to eat better or gain weight. But they have a strong reaction to some foods, typically related to:

• Sensation: They may have experienced distressing gastrointestinal symptoms — pain, reflux or vomiting — from food. Or they may avoid foods because the texture is beyond tolerable. (To one person, “It’s crunchy.” To them, it may be more like chewing beetles.)
• Fear: In the past, the young person may have had a dramatic food-related allergic reaction or choking episode, and they may fear it will happen again. So they decide to avoid the food (and any others the same color) forever.  This may be conscious or unconscious.
• Mood disorder: An undiagnosed anxiety or obsessive-compulsive disorder (OCD) may be causing them to take picky eating to an unhealthy level.

To tease out ARFID, an eating disorder specialist may ask the following questions:

• Do you (or does your child) have sensory issues with food? For example, do they avoid certain textures? Which kinds of foods do they avoid? Which foods are easy to get in?
• What did you (or your child) eat yesterday? How much of (whatever the food named)? What liquids did you (they) drink?
• What are mealtimes like at your home?
• Are you an anxious person (asked to the child)? Any panic attacks? Do you feel depressed? Any obsessive-compulsive (OCD) tendencies (Do you have to do things a certain way, or have certain rituals that you feel compelled to do to feel OK?)
• Do you (or does your child) have difficulties with transitions?
• In thinking about expanding your child’s palate or getting to a more balanced meal plan, what have you already tried?
• Do you drive for miles searching for that one tolerable food?

Treating a complex eating disorder takes a team

“Once we diagnose ARFID, a team of highly trained professionals can help move the person and family towards recovery,” says Dr. Rome. “Recovery takes time; there is no speedy fix.”

In addition to a primary care provider, the treatment team may include:

• Behavioral health specialist: A specialist with experience treating anxiety and disordered eating might use breathing, relaxation or other techniques to help ease anxiety or help the individual master new foods.
• Occupational therapist: An OT can help with swallowing, positioning or posture while eating. They might also use biofeedback, and treatment may include playing with or touching foods to help overcome food-related fears.
• Dietitian: A dietitian can help you meet nutritional needs during treatment and target which foods to tackle first.

At home, Dr. Rome suggests starting with foods you (or your child) enjoy and then slowly introducing new foods. “It can take 25 to 50 times before someone with ARFID no longer sees it as ‘new,’” she explains.

Another technique is “chaining,” which links foods someone will eat with foods they won’t. For example, if you love pancakes, try waffles. If you eat cheese pizza, add a little pepperoni. It works to switch back and forth between the accepted food and the new food to help with the transition.

“The process is slow and deliberate,” says Dr. Rome. “It can take up to a year to overcome ARFID completely. But within a month, we usually start to see some progress.”