When are we going to stop treating ARFID as a behavioral disorder?
Plus some science and tips for trying new foods for my friends with ARFID
For folks in the ARFID community, trying new foods can feel like a nightmare. Since the diagnosis has only been in the DSM since 2013, treatment approaches are still quite premature. Treatment methods for the disorder are based on treatment for childhood picky eating, such as changing familial feeding dynamics, behavioral interventions, or using cognitive behavioral therapy encouraging folks to “change their perspective” in order to “change their experience.”
But many teens and adults with ARFID have been subjected to these treatment methods for most of their lives with little to no improvement, or worse, more food trauma. These folks have been made to believe that if they just try a new food enough and “change their perspective”, they’ll eventually like it. But because none of worked, many develop a deep sense of shame that paralyzes their progress even more.
Currently, part of the issue with developing evidence-based treatment methods is that ARFID includes such a broad spectrum of feeding difficulties, that it is challenging to assess treatment progress in studies. Fortunately for the ARFID community, there are plenty of providers working hard to develop adequate treatment methods and train others, but sometimes it feels like the tools we need can’t be created or shared fast enough.
It’s not “all in their head”
As an eating disorder dietitian, one of the issues I notice with ARFID treatment is that similar to all psychological disorders, we forget about the influence of a person’s physiology on their disorder. We observe, blame, and treat their behaviors without fully investigating the physiology that created the behaviors. And because the investigation of psychological disorders is ruled by… psychologists… I notice that lots of eating disorder treatment tends to gaslight an individuals physical experience. Like hello?? Psychology is physiology! And if we’re talking about food this much, can we get a gastronomist involved?!?1
As clinicians, we’ve been told that a food aversion can come from
lack of interest
fear of consequences (such as illness or choking)
sensory issues (such as extreme avoidance or seeking).
After years of working with folks with ARFID I can’t help but wonder, who decided to segregate these experiences into different categories? And after working with such a diverse population, why do we continue to codify one’s lived experience? We’ve even been told that some of these food issues are based on personality traits!!! But I want to know who decided that? If it’s true, how do we interpret the experience of all folks who seek intense sensory stimuli in some areas of their life, but still can’t tolerate stimuli from food?
Although every case is different, for most folks with ARFID, trying a new food can be a very unpleasant experience. Most are told to just “keep going” or are given tools without any understanding as to how they work. They’re told that their refrain is simply “stress” and “fear”… but again, when are we going to see stress and fear as physiological and not behavioral?!?
Right damn now!
The Physiology of Taste
A lot of folks with ARFID tend to have some similar complaints about food: it tastes bad, it tastes bland, the taste is too strong, it makes me gag, I feel too full, I feel nauseous, I have a knot in my throat, the food is dry.
A lot of these complaints can be caused by a wide range of issues, and fortunately clinicians are usually trained to test for anatomical abnormalities that might cause such - such as tongue-tie, or slow gastric motility. Some can even be associated with the number of taste buds on one tongue! But a lot of these complaints are also associated with stress.
One order of panic with a side of “get me outta here”
In order for our body to digest food, it needs to be in a state of “rest”. In a rested state, nerve signals communicate to our mouth, throat, and stomach to anticipate food. Our mouth produces saliva, which breaks down starch foods to help us taste them. Chewing breaks up food, releasing flavor molecules from the food so we can taste them. The production of saliva sends a cascade of signals to the following digestive organs, telling them to produce digestive juices and muscular contractions.
But when we are stressed, either from fear, chronic anxiety, or even simply from exercise, our body turns our digestive system off so that it can focus all it’s blood and energy on organs and muscles that will in theory get you out of the stressful situation as opposed to “wasting” energy on digesting food.
As a result, your digestive organs and senses will send information to your brain to discourage you from eating food. With low stress, this might look like simply not having an appetite or interest in food. With high stress, this could look like developing a dry mouth, food feeling “bad” in your mouth, gag reflex, smell aversions, nausea, stomach aches, and difficulty swallowing. During a panic attack, this could look like vomiting or diarrhea.
There are many ways to reduce stress for an individual, such as creating a comfortable environment, medication, and therapeutic skills, and also the combination typically reduces stress but doesn’t eliminate it. Considering how distressing trying a new food is, a sensory-heightening stress response is bound to occur during food exposures, whether at the beginning, middle, or end of the experience. The stress is bound to happen, and to some degree needs to happen. But! There are so many wonderful tools that actually target the sensory distress induced by food.
Sensory Management Tools for Trying New Foods
Here are some tools for managing stress-related sensory issues whilst trying new foods!
Sensory cancelling - The are many people with food issues who generally find certain sensory inputs distressing. Such as noise, temperature, pressure on skin, air drafts, messes, etc. If distressing sensory inputs at present at the time of eating, your overall sensory reaction will be heightened and harder to navigate. Figure out what your major triggers are, and find a way to cancel them out. For example, some people may dim the lights, turn off the kitchen fan, wear headphones, wear a beanie or sweatshirt, or sit on a comfy chair. For folks who have low body temperatures, I highly encourage literally “warming up” to cook or eat by doing some light stretching, taking a warm shower, or going for a gentle walk.
Think of food - thinking of food triggers your vagus nerve to stimulate your digest muscles, helping prepare the GI system to received food.
Smelling food - smelling food triggers your brain to send signals to your mouth to salivate.
Seeing food - seeing food, especially for an extended period of time will also trigger your brain to send signals to your GI muscles to start contracts. Some folks find that watching cooking videos, scrolling through recipes, or simply cooking can be helpful.
Cooking your meal - spending the time can cook your meal before you eat it can help put a lot of people in the mood to eat. The extended period of time interacting with food while cooking helps you see and smell it to develop the triggers mentioned above. Additionally, cooking can help a lot of people mentally transition to the eating and help their bodies relax to be open to food. Engaging with food can help folks familiarize their senses (sight, touch, smell), so they know what to anticipate from the food.
Although, it’s worth mentioning that cooking can be so distressing for some folks that doing so before for a meal might be counter-intuitive. Alternatively, you can sit in/near the kitchen while someone else is cooking so you still benefit from the smell and cooking process without causing too much distress.
Suck on something sweet - Sucking on a sweet food can also help you make saliva, which send a cascade of signals down the GI tract to also anticipate receiving food. You can use a hard candy, popsicle, piece of chocolate, or even let a piece of bread or cracker dissolve on your mouth before swallowing.
Start with something starchy - Carbohydrates, especially simple carbohydrates, are the easiest macronutrient to digest, and consequently don’t make you feel super food. Even if stress is preventing you from having an appetite, taking a few bites of a simple carbohydrate before a meal can help you produce saliva, stimulate your swallow reflex, and triggering contractions in your stomach to start digesting food.
Put a bit of salt in your mouth - Putting a touch of salt on your tongue, or letting a salty food item (such as a chip), dissolve on your tongue also helps produce saliva!
Deep breathing - deep breathing can help activate your parasympathetic nervous system, helping your entire GI tract to start creating contractions and chemicals that help you digest food. It also calms your brain down helping you mentally transition to eating.
Take a few sips of a beverage - drinking water or juice can help moisten your mouth to make it easier to taste food. Additionally, it encourages the swallow reflex, warming your muscles up to perform the motion of swallowing food (this is helpful for folks who are prone to experiencing a gag reflex).
Once you’re actually eating
All of the above tools can help you prep your body for a meal, but can also be used during the meal. As you try a new food, there may be surprises that arise in the experience that overwhelm you, thus triggering the stress response. Food may suddenly feel dry, bland, overpowering, etc. Taking a break and returning back to the skills mentioned above can help make the next few bites easier.
Relax your muscles ! - Often when folks with food aversions try new foods, natural reflexes like oral muscular contractions (“making faces”, pushing out food, odd chewing patterns, wincing), occur to help the body cope or eliminate food from the mouth. However, often this leads to ineffective chewing methods, higher likelihood to gag, and reinforces to the brain that panic is happening. An adult who is guided to “ride the wave” and relax their oral muscles a bit will often have a less intense sensory experience.
Super Important note!!!! This is a tricky method to facilitate, and should be used with caution and care! The use of “making faces”, wincing, spitting out food, or gagging is typically associated with so much shame, that these behaviors should also be normalized and welcomed. I’ve seen this strategy used in behavior-based models, but typically associated with force. That being said, I’d only recommend trying it with adults that you have stellar communication & trust with to avoid causing more harm. If it’s used correctly, adults I’ve worked with are often amazed by how much of a difference it makes. Yet I’ve heard of stories in which it has caused a lot of harm to kids. Personally I see it as an “advanced” skill that I vet a person carefully before using!
Chew well - chewing gives our saliva a chance to break down starches, and our teeth a chance to break down the tougher fibers in food. Inadequate chewing can cause pain while swallowing, and can even lead to stomach pain!
Literally just keep chewing - because chewing releases flavor, sometimes the act of chewing more mechanically complex foods (such as fiber and protein) can make the flavor more intense. This can scare a lot of folks who thought the first few chews were mild, and expected the mildness to continue. BUT, because chewing releases flavors, once released and dissolved the will dissipate, much like the experience of a stick of gum losing flavor as we chew. Chewing through the flavor can help reassure the brain that the intensity is temporary, and gives the brain another tool to manage the discomfort as opposed to simply avoiding. Although, this is an advanced skill!! No one should be forced or force themselves to chew through a unreasonably distressing flavor!!
The above list is hopefully a simple guide to help one understand the physiological relationship between stress and taste. If this article benefited you, I’d love to hear how in the comments! It’s so important that we share our lived experiences with ARFID so that we can normalize others experiences.
As a reminder, this is not an exhaustive guide to treatment methods, and the tools above may not work for everyone. It’s always best to work with a treatment team to come up with an individualized process to trying new foods!
Yes, I know an RD is part of the team (such as myself), but we should have more training in gastronomy.