970x125
Emma stepped into her middle school cafeteria and spotted her two friends already settled at their usual table. She was a little late—but for a reason. She knew what was on the menu today, beyond the always-available pizza, bagels, and mac and cheese.
The smell of fried fish and peeled oranges was already drifting through the room, rising from the kitchen and spilling onto other students’ plates. It turned her stomach. An hour earlier, she’d been hungry, but now her appetite vanished. Fish and oranges were among several smells that quietly shut down her desire to eat, transforming hunger into aversion.
Emma also noticed that her friends didn’t seem affected by the odors that overwhelmed her. The smell of bananas or oranges made her gag, yet her friends walked into the cafeteria without a second thought. Their ease only heightened her sense of isolation.
Emma felt embarrassed by her intense reactions to food smells and tastes—reactions she couldn’t control. It wasn’t just eating that was hard; simply entering a room where those smells lingered felt nearly impossible.
Emma had learned to make excuses when certain smells made eating with her friends unbearable. Some days—like today—she hoped the smell of fried fish wouldn’t drive her away. She just wanted to sit with her friends at lunch, eating the carefully packed meal she’d brought from home, safely free of foods she found overwhelming.
Emma had been diagnosed with avoidant/restrictive food intake disorder (ARFID) just a few months earlier. Her physician became concerned when she wasn’t growing taller as expected for her age. When asked about Emma’s eating habits, her mother explained that Emma couldn’t tolerate foods containing bananas, oranges, apples, or most fruits—and the taste was even more unbearable than the smell. Emma avoided nearly all vegetables as well. When fish was cooking, the smell alone was enough to send her retreating to her room.
At first, before she knew about ARFID, Emma’s mother worried that her daughter might have an eating disorder. Emma wasn’t gaining weight like most kids her age. But unlike many of her peers, she wasn’t concerned about her body size and had no interest in knowing her weight. What upset Emma most was that she wasn’t growing. She desperately wanted to be taller.
Emma’s physician was familiar with feeding disorders such as ARFID. Often diagnosed around age 11 and frequently persisting into adulthood, the most common presentation involves heightened sensitivity to food’s sensory qualities. Textures—like the skin on a grape—or consistencies, such as lumps in food, can be overwhelming. Even combinations of textures, like sauce mixed into pasta, may be intolerable.
Strong reactions to smells and tastes can lead someone to avoid entire categories of food and to feel anxious about trying anything new, out of fear of a negative experience. Visual cues can be just as challenging. Burnt edges, a crusty surface, or unexpected colors can quickly turn a meal into something distressing.
Often, a child—or even an adult—can’t explain exactly why certain foods are distressing, only that they feel “disgusting” or that something about them isn’t right. No amount of coaxing, pressure, or insistence seems to change this reaction.
Insisting someone eat feared foods or try new ones often increases frustration for both the individual and their loved ones. Family members or friends unaware of ARFID may find themselves arguing over food reactions that seem unreasonable, while also worrying—rightfully—about the health risks associated with inadequate nutrition.
The net result of ARFID can be tolerance of only a narrow range of foods. Over time, foods tend to fall into categories: “safe,” “unsafe,” or somewhere in between. Foods in the middle may be tolerated but not enjoyed.
For example, Emma couldn’t eat most vegetables, but she could manage mashed potatoes in almost any form. She didn’t particularly like them, but she could eat them if they were served. She wouldn’t choose them from a menu, yet if they appeared on her plate and she was hungry enough, she could get them down.
Emma’s physician recommended vitamins and nutritional supplements to help make up for the nutrients missing from her diet. Because Emma tolerated pills well and enjoyed supplement drinks, adding them was manageable. Over time, nutrient-dense shakes and vitamin supplements helped improve her growth pattern.
At her physician’s request, a dietitian and a psychotherapist experienced in treating feeding disorders like ARFID joined Emma’s care team. The dietitian helped Emma sort foods into categories: safe foods, unsafe foods, and foods she could tolerate but didn’t enjoy.
Seeing the lists written out was eye-opening for Emma. She was surprised by how many foods she avoided—and by how few she actually enjoyed. French fries were acceptable, while her preferred foods included meat and cheese sandwiches without condiments, plain hamburgers, and mac and cheese.
Both the dietitian and the psychotherapist were aware that forcing Emma to eat to improve her nutritional status would only exacerbate her eating issues. Treatment would be a step-by-step, gradual process.
Avoidant/restrictive food intake disorder is a relatively new diagnosis and includes three main presentations: fear of aversive consequences from eating certain foods (such as choking), sensory-based avoidance like Emma’s, and a low interest in food or poor appetite. These patterns can overlap in the same individual and affect boys and girls at similar rates.
Temperamental risk factors for ARFID may include anxiety disorders, autism spectrum disorder, and attention-deficit/hyperactivity disorder. Physical risk factors can include gastrointestinal conditions or other medical issues related to feeding that lead people to avoid foods they associate with illness or discomfort. Emma remembered vomiting once after eating banana bread—one of the few experiences she could link to the development of her food avoidance.
Evidence-based treatment for ARFID is typically provided by a multidisciplinary team that includes medical, dietetic, and mental health professionals. There is currently no U.S. Food and Drug Administration-approved medication specifically for ARFID. Treatment focuses on improving nutrition, reducing anxiety related to food and eating, and helping individuals return to healthful functioning around food and eating.
In family-based therapy, Emma’s parents learned how to guide and support her eating as she gradually introduced new foods. Treatment incorporated principles of cognitive-behavioral therapy adapted for ARFID, including gradual, planned exposure to foods once feared. Emma’s parents also learned to reduce past patterns of accommodating Emma’s food fears, such as serving only safe foods. They provided a positive meal environment and thoughtfully and progressively reintroduced foods Emma had previously avoided.
Emma’s treatment team helped her and her parents better understand her patterns of food avoidance. They thoughtfully chose and prioritized which foods to add, focusing on those that would be most beneficial to her daily life. For example, since fruit was a regular part of family meals, it became a treatment priority.
Emma’s parents decided to start with oranges—a smell Emma frequently encountered with friends and one that had sometimes driven her away from the cafeteria table. Emma improved her ability to remain present with friends and spend more time in social moments she valued after learning to overcome her aversion to the smell of oranges and other common cafeteria smells.
To broaden her food choices, Emma needed to manage the anxiety that came with trying feared foods. After breathing to reduce anxiety or distracting herself with a comedy show, she took one more bite of an orange offered by her supportive parents, marking the first step toward balanced nutrition and better physical and mental health. Each small success reinforced her confidence that anxiety could be tolerated—and that change was possible.
