Being invited to a friend’s house for a meal is an occasion most people look forward to — but not Liz Morris. She’s unable to eat food with certain textures or tastes, including meat and vegetables, so any such invitation sends her into a spiral of panic. But while Liz’s eating patterns might sound like those of a fussy child, she is in fact a 61-year-old retired NHS worker from Dorset. And although she has been labelled a ‘picky eater’ for most of her life, Liz has actually been diagnosed with a little-known eating disorder. Those affected can eat only a very limited handful of foods that don’t cause severe revulsion.

Her condition, avoidant restrictive Food intake disorder (ARFID), was only medically recognised in 2013, although it has affected Liz her whole life. ‘Certain textures — mashed potato and some overcooked textures of vegetables, fish and meat — made me gag and it was impossible to swallow them,’ says Liz, who recalls mealtime battles dating back to when she was a toddler. Liz Morris has ARFID disease, an inability to eat certain textured food Experts say that as ARFID usually first appears in childhood, it’s vital to address it early before it becomes entrenched and more difficult to treat. Pictured: File photo of child refusing to eat

‘I remember my mum trying to feed me food and I just didn’t like it,’ she says. ‘I’ve never been able to eat meat. It just lodges in my throat and makes me gag. And with fish, I can only eat cod — and, even then, only from a particular fish and chip shop.’ School lunches were a nightmare: unable to stomach what was on offer, Liz would sometimes faint from lack of food. She recalls: ‘I have a clear memory of my first day at school. At lunchtime, we all had a plate with a slice of meat, some boiled potatoes and something I did not recognise put in front of us. ‘I would not even open my mouth to attempt to eat it. I just knew that I absolutely couldn’t. By the end of the first week, the headteacher told my mum that I must go home for lunch, as I had to eat something.’ As the family lived a mile from the school, they decided the best solution was for Liz’s mum to walk an extra couple of miles every lunchtime (pushing her little brother in a pram) to take Liz to her grandmother’s house nearby for a sandwich. The family GP, she says, had no idea about eating disorders, simply telling Liz’s mother that her daughter had a narrow throat. ‘That was it,’ says Liz. ‘No help whatsoever.’ So the family learned to stick to Liz’s ‘safe foods’. She says: ‘I would eat chips; fish fingers (only Birds Eye); white bread; ice cream; eggs (preferably scrambled but never cold); cake, as long as it contained no fruit; Heinz oxtail soup, with all the meat bits sieved out of it; peeled apples; Rice Krispies and Weetabix; crisps (cheese and onion or ready salted) and Ritz crackers. I would drink milk, too. ‘It’s easier to list what I couldn’t eat: meat, vegetables, pasta, pizza and fruit (except apples),’ says Liz. And not much has changed since, although she will also now eat very crispy bacon, granary bread and roast potatoes. Deep fried scampi has replaced fish fingers, which she now cannot stomach, and apples have also fallen off the list. Experts say that as ARFID usually first appears in childhood, it’s vital to address it early before it becomes entrenched and more difficult to treat. Central to this is understanding the difference between a child having ARFID and a child who is a fussy eater. Dr Gillian Harris, a clinical psychologist at the University of Birmingham, who specialises in treating ARFID patients, has been researching child feeding behaviour and appetite regulation for the past 30 years. She says that the condition — previously known as selective eating or perseverant eating — only became a clinically recognised condition ten years ago when it was included in the U.S. Diagnostic and Statistical Manual of Mental Disorders (DSM), widely viewed as the psychiatrists’ ‘bible’. Although it first occurs in childhood, it can be diagnosed at any time in life, Dr Harris explains. ‘It manifests as an inability to eat certain foods due to their sensory components [i.e. their smell, texture or taste], and a lack of interest in eating foods other than those that are felt to be ‘safe’,’ she says. She stresses that this goes far beyond fussy eating — there may also be a fear of choking or being sick. ‘Children will literally gag or refuse food and go without for days rather than eat,’ she says. Typically, the foods they will eat are what we regard as ‘junk’ food — basic carbohydrates such as bread and dry cereals, crisps, biscuits, chocolate and yoghurts. ‘These are all easy to process in the mouth and can be swallowed easily — they don’t need a lot of chewing,’ Dr Harris explains. What’s more, she says, they are also bland-tasting, don’t have strong smells or mixed or slimy textures — and they always look and taste the same. People with ARFID can also be very specific about which brands and flavours they like — ‘such as Warburtons bread, for instance, because of the ‘safety’ — they know the texture and know it won’t change,’ Dr Harris adds. Adults and children affected eat a narrow range of ‘basic’ foods, often repeating the same meals every day. The condition is so little known that there are very few designated ARFID services and no reliable data about how many people have the condition. It’s also very difficult to get a diagnosis — as Liz Morris was to discover. Typically, the condition becomes apparent by the age of three — often when solid food is introduced, particularly lumpy or textured food that an infant might gag on. Dr Harris adds that all toddlers are ‘programmed’, from an evolutionary point of view, to be highly cautious of trying new things in case they are not ‘safe’ (known as being neophobic, or afraid of trying new foods) — but some never grow out of this stage. ‘This is not a child being naughty,’ says Dr Harris. ‘The neophobic response is seen in all mammals.’ But although ARFID is a recognised condition, it can also form part of other disorders and can be difficult to diagnose, warns Jane Ogden, a professor of health psychology at the University of Surrey, who has an expertise in eating behaviours. She says: ‘ARFID can be part of obsessive compulsive disorder (OCD) or anorexia, and it often isn’t diagnosed on its own as a condition.’ The trouble is that others outside the family, say, see it as picky or fussy eating, which leads to it being normalised, so the parents think it will go away. Indeed, the term ‘fussy eater’ causes many problems, says Dr Harris, not least because it implies the condition is the parents’ or the child’s fault. This can lead to the wrong advice being given, she says, such as: ‘ ‘Leave them, they will eat when they are hungry’ — but they often won’t! And without treatment it could get worse’. In fact, many people have issues with the taste or texture of certain foods, says Dr Harris, but ‘mostly we can work around this — we have enough other foods to make up a good balanced diet.’ But problems begin if the person is so disgusted by the taste, smell and texture, and so fearful of trying anything new, that they eat only a very small handful of foods — potentially all carbohydrate-based. ‘The last child I assessed could eat only three foods,’ she says. This can impact their growth, health and ability to join in social activities involving food — and, along with the sensory disgust, are all factors in the DSM definition required in order for someone to be diagnosed with ARFID. Experiencing this strong feeling of revulsion can have its roots in an individual’s biological make-up, adds Professor Ogden, but it can also be learned by copying other people’s reactions to food. ‘So there’s an inherent version of disgust, but there’s also a learnt version,’ she says, explaining: ‘This can spiral, so you associate disgust with certain textures and you can become preoccupied with this, generating even stronger feelings of disgust.’ ARFID can also be triggered by a specific event, which people come to associate with that food, adds Professor Ogden. Liz cannot recall a…

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