Selective Eating Disorder and Picky Eating

[icon name=”user” class=”” unprefixed_class=””] Joanne P. Shelby-Klein BSN RN

Teen Girl Eating A Tomato A picky eater, we all know someone (usually a child), who fits this description or we may be one ourselves. What exactly does it mean and is it harmful? Picky eating is actually classified as a spectrum or continuum of feeding difficulties that ranges from simple picky eating at one end of the spectrum and eating disorders that are severe at the other. Picky eaters are also known as fussy eaters who only eat very few types of food, faddy eaters who eat favorite fad foods, and selective eaters who only eat certain specific foods. They can also be classified as food neophobes because they have a fear of certain types of foods, even new foods. There is even an official diagnosis in the DSM-V known as Selective Eating Disorders.

IS THERE A DEFINITION OF A PICKY EATER?

There is no consistent definition of a picky eater at this time. The term usually refers to children who eat a limited quantity of food, will only eat certain types of food, will only take in small amounts of certain foods such as vegetables and or refuse to try any new foods. Picky eating is not classified as an eating disorder but is instead considered to be related to behavioral health. Some children grow out of their pickiness about food while others carry the picky eating habits into adulthood. This leads to concerns about how the lack of variety in foods as well as not taking in the correct amounts of essential nutrients needed to achieve and maintain good health.

WHAT CAUSES SOMEONE TO BE A PICKY EATER?

There are a number of factors that influence a person’s willingness to eat a variety of foods versus being a picky eater.

Determining who will be a picky eater can begin during pregnancy. Flavors from the foods mothers eat during pregnancy or when breast feeding can reach the baby through the amniotic fluid and breast milk. If the mom eats a variety of foods during the pregnancy, then the baby will be exposed to a variety of flavors and be less likely to be a picky eater later in life. A study of 127 children who were breastfed for 6 months showed 78% lower odds for preferring foods prepared a certain way, an 81% lower odds for food rejection and 75% lower odds of developing new food avoidance or food neophobia.
Genetics may also play a part in determining who will be a fussy eater. There are specific genes that rule over taste and all the variables involved in how strongly or weakly that taste is perceived. A study conducted in Philadelphia determined that kids who were more sensitive and responsive to bitter tastes, preferred sugary drinks and sweets.
Babies who have trouble eating early in life because of colic, frequent vomiting or spitting up, or have trouble with sucking and slow feeding may be more at risk for being a picky or selective eater later in life.
Picky eating has been found to be more common in the first born child.
Babies who are introduced to solid foods after 9 months of age or weaned from breast feeding improperly are also found to be at risk for being a picky eater.
Babies who receive very little variety in food tastes and textures when starting on more solid food or given few new food choices are more at risk. Also if the feeding times are unscheduled or poorly planned the babies may be at risk for poor eating habits when older.
Sleeping patterns and habits that are erratic and frequently disturbed can also affect how the child eats. If there are conflicts between the parent and child at bedtime or meal time it can also lead to picky eating.
If the parents, mainly the mother, has a history of eating or food issues, anxiety or depression and body image concerned can be a predicting factor for picky eating in the children.
Picky or selective eating may also be a symptom of an underlying problem such as autism or developmental disability. 80% of children who have a developmental disorder also have some form of an eating disorder. A study completed at Penn State University showed that children on the autism spectrum had some form of selective eating disorder and preferred foods like nuts and whole grains putting them at risk for obesity and other chronic health problems.

HOW IS PICKY OR SELECTIVE EATING DIAGNOSED?

It can be difficult to determine if someone, especially a child, is a picky or selective eater. An official diagnosis of Selective Eating Disorder should be considered and explored if any or all of these are observed or present:

Parents are seeing and are concerned about an abnormal pattern of eating including what they prefer or avoid in food choices, they eat slow or do not finish meals, limit foods eaten to certain colors or textures, or behave abnormally with certain foods.
Health Care Professionals notice on physical exams or office visits that growth in children seems very slow or not at all, lab work shows a lack of important nutrients, overweight or obese, chronic illness, abnormal behaviors or acting out behaviors, trouble sleeping, anemia, constipation, tension among family members.
May be noticed after the age of 2 or whenever the child begins to eat independently and lasts for at least 30 days.

If any of the above is observed, a thorough history and physical exam is needed and should include the following:

FOOD CONSUMPTION:

Dietary recall of all food consumed in a set period
What textures, temperatures and colors of food are consistently eaten or avoided.
Does the person eat a variety of foods or a limited number of foods?
How often is the person exposed to new food and how do they react to the new food?
Using the food pyramid as guide, what food groups and types are eaten and when.

MEAL TIME BEHAVIOR PATTERNS:

What is the normal meal duration for the family?
How long does each meal actually take?
What times of the day is the normal meal time?
How does the patient participate in meal times and family times?

PHYSICAL EXAM AND MEDICAL HISTORY:

Height and Weight and Body Mass Index (BMI) and relationship to previous visits and what is normal for age group.
Typical energy and activity level
Evaluate lab work for vitamin and mineral deficiencies and observe for physical signs of deficiency.
Discuss normal bowel patterns. Is there a problem with constipation or diarrhea?
Is the child having trouble with learning and IQ for their age group?
Have an eye exam performed by an ophthalmologist
What is their normal sleep pattern and has it changed?
Are they getting frequent colds or other minor infections?
Do they have any food allergies such as lactose intolerance or allergy to milk?

WHAT PROBLEMS CAN OCCUR WITH SELECTIVE EATING DISORDERS?

Patients with Selective Eating Disorders are at risk for many long term health problems. The simplest is issues with food choices into adulthood. The more complex and dangerous include anorexia, disturbed growth, abnormal behaviors and acting out and most importantly vitamin, mineral and other nutritional deficiencies. People who are selective or picky eaters may also be at greater risk for anxiety and depression. A recent study released by Duke University shows that children who are diagnosed with severe selective eating disorder were at least twice as likely to have a diagnosis of depression and or social anxiety disorder. This study points to picky or selective eating as a problem that will not go away by itself over time but instead needs to be monitored over time and treatment started including a team/family approach to the problem.

WHAT CAN BE DONE TO TREAT PICKY EATING?

One of the first steps in treating picky or selective eating is to have the person checked for any medical issues that may be causing the problems such as:

Gastro-intestinal (GI) tract not working properly
Allergies to certain foods
Sensitive to food temperatures
Patient does not like messy hands or face
Check gag reflex to see if certain textures of foods causing gagging on a daily basis
Do they always prefer squish and swallow foods?
Do they have trouble keeping any particular foods or liquids in their mouths?
Do they seem to fuss and cry at meal times?

It may be necessary to have a Speech Therapist or Occupational Therapist work with the person if any of the above is noticed.

BEHAVIORAL MODIFICATION (CHANGING THE BEHAVIOR ASSOCIATED WITH EATING)

This is the most time consuming part of treating picky eating. It involves recording, rewarding, relaxing and reviewing the persons eating habits so that positive changes and results happen.

Have the person record their normal eating habits in a log making sure to include how long it took them to eat, what they ate, how much they ate and how they felt about it.
Have the person create a list of foods they would like to try someday. The goal is to get the person to try and eat new and different foods. Create a reward system where they receive a toy, sticker or token for trying taking bites of something new and keep the bites small until they get used to eating it.
Keep the spoon or fork in front of the person until they try a bite. Do not remove the new food and substitute with the persons preferred food. If necessary and it is a child refusing the food, apply gentle pressure to the chin and gently insert the spoon. Offer praise when they accept the food.
Create a relaxing atmosphere for the person to eat in. Find relaxing music or a favorite story to help relax the person before eating.

One important thing to remember is that changing a behavior, especially children’s, can result in stress on the parent or caregiver and may produce negative results at first. Children can become more aggressive, have emotional responses like crying or screaming and even attempt to physically leave the meal. These actions may lead to the treatment plan being abandoned to protect the safety of other family members. Should these problems arise, using speech or occupational therapists to begin the behavioral therapy may be the only choice.

It is important to remember that children will often explore new foods by touching, playing with, smelling and even putting in their mouth and spitting back out before they will accept the food and swallow. It is recommended that foods be offered on several occasions to allow this exploring to occur, while they are exploring the new food, you can show them that it is ok to eat by eating the same thing they are. Putting pressure on a child to eat something has a negative effect and tends to make children dislike or refuse to eat certain foods. A study of 3022 infants was conducted and showed that infants and toddlers needed an average of 8-15 exposures to any new food before accepting it. The study also showed that many of parents were not aware of this fact and need to keep the fact that children like to explore food before they eat it.

WHAT ELSE DO WE NEED TO KNOW ABOUT SELECTIVE EATING?

Selective Eating diagnosis and treatment is a challenge for parents and healthcare providers both, especially since 20% of study population at Duke University reported moderate to severe selective eating symptoms. Other studies show that about 15% of children will carry the selective eating behavior into late childhood and even adulthood. This means that there is a chance that they will outgrow it. This provides an opportunity for health care providers can educate parents about normal growth and development including eating patterns in the various stages. It is important to remember that the wait and see if they grow out of it attitude may not be the best attitude since selective eaters may have issues with anxiety and depression. All studies indicate that more research into the emotional, physical and behavioral aspects of selective eating is needed and that the terms picky or selective eating is becoming outdated and obsolete. Additional research will help healthcare providers understand the complex processes involved in selective eating and help them educate parents and caregivers in management.

References

Nancy Zucker, William Copeland, Lauren Franz, Kimberly Carpenter, Lori Keeling, Adrian Angold, and Helen Egger. (2015, August). Psychological and Psychosocial Impairment in Preschoolers With Selective Eating. Pediatrics peds.2014-2386; published ahead of print August 3, 2015, doi:10.1542/peds.2014-2386.
Walsh, J. M. E., Wheat, M. E., & Freund, K. (2000). Detection, Evaluation, and Treatment of Eating Disorders: The Role of the Primary Care Physician. Journal of General Internal Medicine, 15(8), 577–590. doi:10.1046/j.1525-1497.2000.02439.x
Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. May 2013. American Psychiatric Association. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10
Nastanko, N. MS RD CDN. (2014) What if it’s Not Just Picky Eating? Selective Eating Disorder in Children. Retrieved from URL: http://www.foodandnutrition.org/Stone-Soup/October-2014/What-if-its-Not-Just-Picky-Eating-Selective-Eating-Disorder-in-Children/
Selective Eating Disorder. Retrieved from URL: http://www.worldlibrary.org/article/WHEBN0011839182/Selective%20eating%20disorder
Green, R. J., Samy, G., Miqdady, M. S., Salah, M., Sleiman, R., Abdelrahman, H. M. A., … Vandenplas, Y. (2015). How to Improve Eating Behaviour during Early Childhood. Pediatric Gastroenterology, Hepatology & Nutrition, 18(1), 1–9. doi:10.5223/pghn.2015.18.1.1
Caroline M. Taylor^{a, ,}, Susan M. Wernimont^b,, Kate Northstone^c,, Pauline M. Emmett^a. Picky/fussy eating in children: Review of definitions, assessment, prevalence and dietary intakes. Appetite Volume 95, 1 December 2015, Pages 349–359. doi:10.1016/j.appet.2015.07.026
Bachmeyer, M. H. (2009). Treatment of Selective and Inadequate Food Intake in Children: A Review and Practical Guide. Behavior Analysis in Practice, 2(1), 43–50.
Handwerk, B. (2014). Why Are You a Picky Eater? Blame Genes, Brains and Breast Milk.The complicated science behind picky eating is giving experts plenty of food for thought. Retrieved from URL:http://www.smithsonianmag.com/science-nature/why-are-you-picky-eater-blame-genes-brains-and-breast-milk-180953456/#9dG3WyqOJ0yy7bz6.99
Lam, J. (2015, May). Picky eating in children. Front. Pediatr., 06 May 2015 | http://dx.doi.org/10.3389/fped.2015.00041 Retrieved from URL: http://journal.frontiersin.org/article/10.3389/fped.2015.00041/full
Demattè, M. L., Endrizzi, I., & Gasperi, F. (2014). Food neophobia and its relation with olfaction. Frontiers in Psychology, 5, 127. doi:10.3389/fpsyg.2014.00127.