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 Duke-led research 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 findings, published in November 2021 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.

ARFID is characterized by health problems such as weight loss and nutritional deficiencies and can also lead to social and emotional problems when mealtimes become a source of shame, friction, or conflict.

Positive Approaches Highly Favored

“It’s not surprising that positive approaches were favored, but it is surprising how overwhelming that position was among this group of adults,” says Nancy Zucker, PhD, professor in the Duke’s Department of Psychiatry & Behavioral Sciences. Zucker was co-senior author on the study with Guillermo Sapiro, PhD, professor of electrical and computer engineering at Duke’s Pratt School of Engineering.

Zucker, director of the Duke Center for Eating Disorders, says 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.”

More than 19,200 people were included in the survey. 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.

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.

Artificial Intelligence Aided Interpretation

Interpreting the narrative responses from the large 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,” says J. Matías Di Martino, PhD, 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.”

Reducing Mealtime Stress is Essential

“To our knowledge, there is no published research that identifies effective feeding strategies for those with ARFID,” Zucker says. “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.”