SINGAPORE: Sarah* dislikes particular food textures, and has a very small appetite.
While she will sometimes eat very small portions of her dinner, she has started to avoid all green foods. Now she avoids red and orange foods too.
Sarah also has trouble digesting food from time to time.
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This poses a big challenge for her mum, who struggles at meal times to ensure she gets the nutrients she needs to grow and develop.
Sarah is 11, but she looks much younger because she is underweight.
Avoidant/Restrictive Food Intake Disorder (ARFID) is a relatively new disorder first published in 2013 and classified as an eating disorder.
For years, doctors did not have the necessary tools to diagnose children like Sarah. They thought it might have been “traditional” eating disorders like anorexia but eventually ruled those out because patients did not have a distorted body image or a desire to lose weight.
On the surface, it can appear to be many things and is often oversimplified as “fussy eating”. However, individuals who suffer from this condition struggle with an inability to consume adequate caloric intake to sustain nourishment needed for proper growth or maintenance.
ARFID made headlines recently when it was reported that a Bristol teenager who couldn’t tolerate the texture of fruit and vegetables lost his sight permanently after suffering damage to his optic nerves caused by malnutrition from eating only chips, sausages, processed ham and white bread.
Clinical research shows that individuals with ARFID have a short list of safe foods and tend to consume highly processed foods, which they see as comfort food.
Examples include potato chips, French fries, sweets and sweetened beverages. These less healthy foods tend to be high in refined carbohydrates, saturated fat, added sugar and sodium.
People who suffer from this condition tend to pick foods that displaces healthier options that are high in fibre, vitamins, minerals, protein and good fats. Such healthy foods include wholegrains, fruits, vegetables, fish, lean meat, dairy, legumes, nuts and seeds.
Nutrients such as vitamins, iron, and calcium are essential to keep bodies functioning normally.
As a result of a deficiency in those nutrients, individuals with ARFID can present any of the following symptoms: Poor eyesight, dry skin, lowered immunity, poor bone development, lethargy, feeling cold, menstrual irregularities, and brittle hair and nails.
JUST A FUSSY EATER?
It can be hard for parents and health professionals to distinguish “normal fussiness” in a child from a diagnosis of ARFID.
In Singapore, one in two parents consider their children to be fussy eaters, a 2012 study by the National University Department of Paediatrics and Abbot Nutrition shows.
Unlike individuals with ARFID, young fussy eaters aren’t at risk of nutrient deficiencies, and their pickiness goes away with time. In contrast, ARFID remains unless there is psychological intervention.
Fussy eating is normal for children – it is a part of a healthy child’s development as they explore new foods and learn how to be independent.
Children may also go through phases where they dislike the shape, colour and texture of certain foods. Most children are still able to meet their nutritional needs despite some pickiness.
WHAT CAUSES ARFID AND FUSSY EATING?
There’s no single cause for ARFID. Instead, a variety of biological, environmental and psychosocial factors contribute to the condition. The condition might also be triggered by a traumatic event which involve choking or vomiting.
Individuals with attention deficit hyperactivity disorder, autism spectrum disorder and other developmental disabilities may be at a higher risk of developing ARFID.
Various mental conditions may be underlying causes as well, such as anxiety, depression and obsessive-compulsive disorder.
HELPING FUSSY EATERS
Fussy eaters are more sensitive to the smell, taste and texture of foods. Here’s where parents play a role – children may model their parents’ fussy eating habits because that’s how daddy eats.
Additionally, when food is used as a reward, punishment or bribe, the incidence of fussy eating is higher.
Parents can manage fussy eating by offering different varieties of foods and mixing new foods with familiar ones. However, parents or caregivers often tend to stop offering the same food after first refusal.
Sometimes children reject food on the basis of texture, not taste. For instance, a child may be more willing to eat grated carrots instead of carrot sticks or pureed carrots.
Our advice would be for parents not to be too hasty in dismissing foods. It is important for children to develop a healthy relationship with food at a young age. If this does not happen, children are more prone to disordered eating and weight problems later on in life.
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To help kids get over fussy eating, parents can continue to maintain control of what food is available, when and where meals are eaten. Meanwhile, the child can decide how much he or she wants to eat or whether to eat.
This Division of Responsibility in Feeding developed by the Ellyn Satter Institute has been a useful tool for kids to move away from fussy eating.
It is important not to force your child to eat or use pressure or punishment if they do not finish their meals.
Make mealtimes pleasant and not in front of the television or iPad. Let them be fully present at a meal.
Use a meal schedule. If the child refuses to eat, make him sit at the table until everyone is done.
The next meal will be served at the next scheduled time, and don’t let there be two ways about that. Your child will learn quickly that you mean business so you as a parent need to stay on track.
The goal for feeding a fussy eater should be to try new foods and prevent food from becoming the start of a lifelong battle.
Jaclyn Reutens is a dietitian at Aptima Nutrition and Sports Consultants. Sue Anne Nummela is Principal Consultant Psychologist at the Adelphi Psych Medicine Clinic.
*Names used in this commentary are pseudonyms.