Diving Into The Psychology of Picky Eating May Reveal ARFID

Amity Island, 1975. A week before July 4th, a series of shark attacks had ripple effects across the nation. As a direct result, fear of shark attacks and shark cullings rose precipitously. This created a fear of sharks that continues mostly unabated to this day. Steven Spielberg's masterpiece, Jaws, and the subsequent heightened fear of shark attacks have created a situation where most people are illogically afraid of sharks, and some are so afraid they refuse to enter the water at all. I personally love swimming, surfing, and snorkeling. Yet even with decades spent underwater, I still get my hackles up when I see a shark close by. This is in spite of the overwhelming evidence that unprovoked shark attacks are astronomically rare. Despite more than 2 billion visits to beaches in the United States in 2025, there were only 25 confirmed shark bites and one death.^[1,2] To give some perspective, if you live 5 miles from the beach, you are over 100 times more likely to die on the drive to the beach than from a shark attack.^[3] Our collective fear of sharks is, ultimately, irrational, but that doesn’t make it any less real.^[5] Another irrational, but very real problem driven by fear, is Avoidant/Restrictive Food Intake Disorder.

Avoidant/Restrictive Food Intake Disorder, also called ARFID, is a condition in which sufferers avoid eating specific foods to the point of nutritional deficiency.^[4,6] This dangerous, occasionally fatal disorder is characterized by extremely limited food selection, with some people only able to consume a handful of specific foods and others who have trouble eating any foods at all.^[4] ARFID differs from other eating disorders in that food avoidance or restriction is not driven by concerns about body image or weight loss.^[4,7] It is unknown how many people suffer from ARFID, with prevalence estimates ranging from 1-15%, though it seems more common in children.^[4,8,9]

For many parents who have children with ARFID, the condition can be mistaken for being a “picky eater,” but the distinction is vital. People may have an irrational fear of sharks, but that doesn’t make their heart beat any slower or their panic any less real in the presence of the “man in the grey suit”. The common wisdom of “they will eat what I give them” doesn’t apply with ARFID, as evidenced by the host of medical and psychological problems that result, including:^[4,6]

• Significant weight loss
• Significant nutritional deficiency
• Dependency on feeding tube
• Psychosocial dysfunction

ARFID is an involuntary, long-lasting condition and may be lifelong for some sufferers.^[4] It interacts with other medical and psychological conditions to present with an array of signs and symptoms, including:^[4,6]

• Weight loss
• Malnutrition, leading to:
  • Heart problems
  • Electrolyte imbalance
  • Vitamin deficiencies
  • Muscle weakness
• Stomach cramps
• Menstrual problems
• Dizziness and fainting
• Constant feeling of cold
• Dry skin and nails
• Changes to hair
• Poor wound healing
• Immune system changes
• Problems with concentration and sleep

Although great white sharks receive the most media attention, they are just one of many shark species that prowl the seas. Similarly, ARFID presents in three main types: sensory sensitivity, fear of aversive consequences, and lack of appetite or interest in eating.^[4] Sensory sensitivity is an aversion to certain tastes, textures, or smells that makes the experience of eating most food difficult or even unbearable.^[4] Sensory sensitivity is thought to develop from abnormalities in taste perception, including oversensitivity and altered perception of bitter and sweet flavors.^[4] A fear of aversive consequences is the avoidance of food because of increased activity of the gut defense system that spurs extra fear response - usually after some kind of trauma related to food, like choking or throwing up.^[4] A lack of appetite or interest in eating occurs when there is a problem with how the brain interprets appetite.^[4] These three types swim together, and most ARFID sufferers have a combination of them in varying amounts.^[4]

ARFID seems to run in families and develop in childhood.^[4,8] Research has found that ARFID has several possible underlying causes, including gastrointestinal issues, abnormal brain structure, and a maladaptive gut microbiome.^[4,7,8] These factors can increase the likelihood of ARFID, however one complicating factor seems to be that food restriction doesn’t provide relief.^[4] For example, a maladaptive gut microbiome might have fewer bacterial species than normal, which can cause pain after eating certain foods. But restricting the types of foods eaten could allow those few species to further specialize, creating a hard-to-break feedback loop.^[7] These underlying causes then interact with the brain to create back-and-forth chatter that reinforces the negative aspects of ARFID by affecting things like disgust, mood, food reward sensation, our senses, food and energy balance, fear, and thinking about food.^[7]

Unfortunately, on the off-chance you get eaten by a shark, there is not much doctors can do. Similarly, there are only a few treatments (and fewer randomized, controlled trials) for ARFID.^[4] The goal of treatment is typically to increase body weight, reduce malnutrition, and increase the variety of foods eaten.^[4] Direct treatments include vitamins, supplements, feeding tubes, and formula.^[4] The most effective long-term solution, however, is behavior therapy. Different types of behavior therapy include:^[4,9]

• ARFID-specific cognitive behavior therapy that addresses the specific presentation
• Family-Supported Therapy, which includes family members
• Systemic desensitization, where new foods are introduced through play
• Operant conditioning, a reward-based therapy
• Oral-motor skill development
• Sensory play
• Supportive Parenting for Anxious Childhood Emotions (SPACE-ARFID), which is designed to change parental behavior without directly involving a suffering child

This 4th of July, while some of us are enjoying the beach, ice cream, and watermelon, some people will be stuck, afraid of sharks and unable to enjoy many parts of the holiday. In the past 50 years, there have been amazing strides in our understanding of sharks and huge conservation efforts. Swimming forward, if we can design and run randomized clinical trials for ARFID, we may be able to take a bite out of this debilitating disorder.

Creative Director Benton Lowey-Ball, MWC, BS, BFA

References:

[1] Houston JR. The recreational and economic value of Florida beaches. Shore & Beach. 2024;92(3):43.

[2] Florida Museum of Natural History. Yearly worldwide shark attack summary [Internet]. Gainesville (FL): Florida Museum of Natural History; 2026 Feb 17 [cited 2026 Jun 30]. Available from: https://www.floridamuseum.ufl.edu/shark-attacks/yearly-worldwide-summary/.

[3] National Safety Council. Historical car crash deaths and rates [Internet]. Itasca (IL): National Safety Council; 2025 May 11 [cited 2026 Jun 30]. Available from: https://injuryfacts.nsc.org/motor-vehicle/historical-fatality-trends/deaths-and-rates/.

[4] Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT. Avoidant/restrictive food intake disorder: a three-dimensional model of neurobiology with implications for etiology and treatment. Current psychiatry reports. 2017 Aug;19(8):54. https://doi.org/10.1007/s11920-017-0795-5

[5] Sah P, Westbrook RF. The circuit of fear. Nature. 2008 Jul 31;454(7204):589-90. https://www.nature.com/articles/454589a

[6] American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). 2013 May. https://doi.org/10.1176/appi.books.9780890425596

[7] Schneider E, Schmidt R, Cryan JF, Hilbert A. A Role for the Microbiota‐Gut‐Brain Axis in Avoidant/Restrictive Food Intake Disorder: A New Conceptual Model. International Journal of Eating Disorders. 2024 Dec;57(12):2321-8. https://doi.org/10.1002/eat.24326

[8] Moreau CA, Ayrolles A, Ching CR, Bonicel R, Mathieu A, Stordeur C, El Khantour C, Bergeret P, Traut N, Tran L, Germanaud D. Neuroimaging insights into brain mechanisms of early-onset restrictive eating disorders. Nature Mental Health. 2025 Jul;3(7):780-8. https://doi.org/10.1038/s44220-025-00447-x

[9] Shimshoni Y, Silverman WK, Lebowitz ER. SPACE‐ARFID: A pilot trial of a novel parent‐based treatment for avoidant/restrictive food intake disorder. International Journal of Eating Disorders. 2020 Oct;53(10):1623-35.