Positive and encouraging strategies benefit “picky eaters”

Reviewed by Emily Henderson, B.Sc.Nov 11 2021

In a large national survey, adults who struggled with picky eating habits as children overwhelmingly said they benefitted more from positive and encouraging strategies their parents used than forceful or coercive approaches.

The research, led by a team at Duke Health, was conducted among a generation of people who struggled with food avoidance before it was identified in 2013 as a psychiatric condition called Avoidant/Restrictive Food Intake Disorder (ARFID).

The researchers said their findings, appearing online Nov. 11 in the International Journal of Eating Disorders, provide guidance for both families and behavioral health professionals for developing best practices to deal with extreme food aversions.

When picky eating is severe, it is diagnosed as ARFID. The condition is characterized by health problems such as weight loss and nutritional deficiencies and it can also lead to social and emotional problems when mealtimes become a source of shame, friction and/or conflict.

It's not surprising that positive approaches were favored, but it is surprising how overwhelming that position was among this group of adults."

Nancy Zucker, Ph.D., Professor, Duke's Department of Psychiatry & Behavioral Sciences

Zucker was co-senior author on the study with Guillermo Sapiro, Ph.D., professor of electrical and computer engineering at Duke's Pratt School of Engineering.

Zucker, director of the Duke Center for Eating Disorders, said the broad consensus is validation for the current treatment approach that emphasizes positive interactions: "It is robust confirmation for what had been out there in the literature and reinforces the concept that children feeling forced or pressured to eat is not helpful."

The study was launched more than a decade ago as severe food avoidance was gaining attention and research into the disorder was limited. The online survey was aimed at adults who self-identified as current picky eaters to help understand their perceptions and experiences.

More than 19,200 people were included in the survey; 75% were female and 25% were male, and 89% were white. Respondents were asked to describe food presentation strategies used by their parents or caregivers that they found to be helpful or not helpful in increasing food variety.

Survey participants were subsequently classified as either likely having an ARFID diagnosis or not, based on their degree of impairment from food avoidance. Those who reported that eating problems led to significant weight loss, nutritional deficiency, interference with job functioning and/or interference with social relationships were categorized as likely having ARFID.

Interpreting the narrative responses from the huge cohort of participants created a logistical challenge, which was solved with the application of sophisticated artificial intelligence tools.

Using a computational tool to characterize the perceived helpfulness of parent feeding strategies, the researchers applied an algorithm to interpret the meaning and/or sentiment of survey responses to characterize them as helpful or not helpful.

"From a technical perspective, this study used an AI application that understands language, not just words and sentences, but concepts of paragraphs, which was imperative here," said J. Matías Di Martino, Ph.D., co-lead author with doctoral student Young Kyung Kim. Both are in Duke's Department of Electrical and Computer Engineering. "By getting the positive and negative emotions, it enables us to analyze the comprehensive memories of nearly 20,000 people."

The researchers found that 39% of the themes regarding helpful strategies mention a positive emotional context, such as using food to teach cultural or nutritional lessons, being flexible about the approach to food, providing plenty of safe foods, helping with food preparation, or presenting foods from specific food groups.

Forty percent of the helpful comments noted the importance of structure around eating. Clearly defined expectations around eating were deemed to be helpful in the context of distinguishing between feeling "forced" vs. being asked to do something.

While positive and encouraging strategies were perceived as helpful in improving attitudes towards food and minimizing social discomfort around eating, many adults still struggled with a degree of avoidance/restriction. The researchers noted that parents are perceived as having a positive impact despite their children's food avoidance persisting into adulthood.

The researchers said survey participants clearly found some foods aversive, not merely unpleasant. This likely intensified their feeling of being trapped and made to do something disgusting if they were asked to eat that food.

"To our knowledge, there is no published research that identifies effective feeding strategies for those with ARFID," Zucker said. "Figuring out the best way to feed a child with severe food avoidance can be exhausting and stressful for parents, so providing guidance is essential to improve the social and emotional eating environment for their children and reduce the distress that both parents and children have at mealtimes."