When it comes to eating, we all have our own personal food preferences. For example, some people love Brussels sprouts, and some people only like it prepared a certain way. Some people dislike the taste of ketchup and some put it on everything they can. And while recognizing that we are all unique in this way, the more food preferences someone has, the more often they are labeled as a “picky eater.”
The term “picky eater” has been widely accepted in our society, yet it often dismisses the fact that we all interact differently with our food preferences and feeling of safety around food. This can be especially invalidating when “picky eating” and changes in food preferences are a normal part of human development and gaining independence (1).
So how do you know when food preferences start to turn into something more? When these preferences and feelings of safety are quite limited around a large variety of foods, an exploration into an Avoidant/Restrictive Food Intake Disorder (ARFID) diagnosis can be done.
For parents Jordan and Sam, this sure was a question they had for their 4 year old son, Aiden. Jordan and Sam had noticed that Aiden had developed specific food preferences over the last couple years. While Aiden was being introduced to solids, he loved trying new foods – he would try a variety of different tastes and (age-appropriate) textures and Jordan and Sam felt comfortable exposing him to different cuisines and flavours. Aiden had difficulty with certain textures of foods, but they hadn’t posed much of an issue at the time. Jordan and Sam felt this was normal, as they knew that children can go through phases of different food preferences during their formative years.
A few months before his 3rd birthday, Aiden had gotten food poisoning from a beef stir fry he ate quite regularly. This made Aiden feel quite anxious around eating the meal again, and he began associating various foods similar to that dish as “dangerous.” Aiden quickly stopped eating all forms of beef, which Jordan and Sam weren’t too worried about as he still ate a variety of other protein foods, like chicken and fish. Slowly, Aiden started to develop aversions to even more foods, and his doctor started to become concerned with some significant changes in his expected growth.
What is ARFID ?
ARFID is an eating disorder classified under the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (2). It can affect anyone at any age, though more commonly becomes apparent during childhood. ARFID is characterized by restrictive eating behaviours non-motivated by weight or shape and is categorized into 3 main types that can occur independently or in combination:
- Lack of interest in food
- Sensory avoidance of food
- Fear of adverse events/consequences
ARFID manifests as a failure to meet nutritional needs, which can lead to some of the following common signs and symptoms (2):
- Weight loss (or failure to reach expected weight and/or height gain in children/teens)
- Gastrointestinal complaints
- Nutrient deficiencies (ex. anemia)
- Food rituals or rules (ex. only eating a certain brand of corn)
- Anxiety around eating familiar or unfamiliar foods
- Disinterest or refusal to eat certain foods or food groups
ARFID has also been found to be more common in neurodivergent populations (for example, those with Autism Spectrum Disorder or ADHD), those with anxiety disorders, and depression (2).
How to Differentiate Between ARFID and Food Preferences
Jordan and Sam consulted Aiden’s family doctor to express their concerns about his eating patterns. They had been noticing that Aiden’s intake was variable from day to day and would sometimes eat foods he had previously refused. In collaboration with a registered dietitian and psychologist specialized in ARFID, Aiden’s healthcare team began investigating his case.
While this is not a comprehensive list by any means, when differentiating between ARFID and food preferences, here are 3 key points to consider (especially for a child transitioning from being a toddler to a preschooler, like Aiden):
1.Habits do not improve with age: Unlike the taste changes that naturally occur during childhood development (like only eating round, green foods, or stopping to eat chicken), when it comes to ARFID, these changes aren’t “grown out of” over time. It is normal for tastes and preferences to change during these times, and for children to explore their preferences and independence. In a child presenting with ARFID, however, their experience will continue to occur (and can worsen) as they age, especially without treatment.
2. Height or weight gain is impacted: During childhood growth and development, growth curves can be used to monitor their expected height and weight. There are periods of slowed and accelerated growth, which can impact appetite in turn. In the case of toddlers for example, there is a natural disinterest in food as their growth slows down, and so appetite decreases (1). This is to be expected, and when looking at their growth curves, toddlers tend to continue to follow their curve and percentile. In the case of a toddler with ARFID, given that food intake is heavily restricted, their bodies don’t get the energy they need in order to grow and develop as they would be expected to. This can again be followed on their growth curves, where they may fall off the percentile they were following for their weight and/or height.
3. Anxiety and/or discomfort is felt around unfamiliar foods: While during toddler and preschool years, children experiment with independence and being introduced to new foods, it is normal for there to be resistance. Some research suggests that it can take 8-10 exposures of a new food for a child to accept it (1). In cases like ARFID, more severe distress can be felt around these new foods, especially ones that don’t feel “safe” to them. This can be seen in a more heightened way during eating times at school; for example, a child with ARFID can become extremely uncomfortable around foods their classmates have, and eating can become quite challenging.
In examining Aiden’s case, his medical team had run a variety of tests and determined that the worsening of his food aversions, significant interruptions of his growth, and newly present iron deficiency were signs of developing ARFID and he began treatment shortly after.
A Quick Note About ARFID Treatment
When it comes to the treatment of ARFID, it should be individualized for each person and the severity of their food limitations. With that being said, one of the main goals of treatment is to find adaptations to avoid (and treat any current) malnutrition. Expanding one’s “safe foods” list can be done in an effort to restore weight and/or correct nutritional deficiencies, but it doesn’t have to be to expand it so that they like all foods. If someone wants to explore new foods, a focus can be on learning to tolerate trying new foods, in a variety of settings. Removing the pressure of having to like new foods can support this process. This needs to be done at one’s own pace and comfort level; there is no expectation that treatment should be done at a certain speed or rate. It is also normal that some people will always have ARFID-related food preferences, and it is completely valid if they prefer to meet their nutrition needs with a more limited food selection.
Conclusion
Differentiating between ARFID and normal developmental changes with food can be difficult to do, but looking for support can be the best way to understand what’s going on. Although the focus of this article was on 4 year old Aiden, ARFID can impact anyone of any age. If you or someone you know feels like eating and finding foods to eat is a challenge, don’t hesitate to contact the dietitians at Sööma for support by phone at (514) 437-4260 or by email at info@sooma.ca. We’d be happy to hear your story and support you in finding ways to improve your eating experience, no matter if it’s navigating ARFID, ARFID-like symptoms or more restrictive food preferences.
References
(1) Brown, J. (2011). Nutrition: Through the life cycle (Fourth Ed.). Cengage Learning.
(2) Avoidant/Restrictive Food Intake Disorder. (n.d.) National Eating Disorders Association. Retrieved from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
By: Justine Chriqui, Registered Dietitian
Sööma est une entreprise bilingue qui fonctionne en anglais et en français. Nous fournissons des articles de blogue, des recettes et des articles de diverses sources qui sont parfois écrits en anglais et parfois en français. Si vous vous sentez incapable d’accéder à un article ou à un sujet spécifique en raison d’une barrière linguistique, veuillez nous contacter à info@sooma.ca et nous serons heureux de traduire le contenu pour vous.
Sööma is a bilingual company that operates in both English and in French. We will provide blog posts, recipes and articles from various sources that are sometimes written in English and sometimes in French. If you feel unable to access a specific article or topic due to a language barrier, please reach out to us at info@sooma.ca and we will be happy to translate the content for you.
References
(1) Herrin, M., & Larkin, M. (2013). Nutrition counseling in the treatment of eating disorders (2nd ed.). Routledge/Taylor & Francis Group.
(2) Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). Guilford Press.
(3) Wisniewski L, Ben-Porath DD. Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management Procedures to Manage Dialectical Dilemmas. Am J Psychother. 2015;69(2):129-40. doi: 10.1176/appi.psychotherapy.2015.69.2.129.
