Many of us have come into contact with picky eaters over the course of our careers. Whether you’re a family physician, a dietitian, nutritionist, a psychologist like I am, or any number of other allied health professionals, the likelihood is that picky eating or fussy eating has been a feature of some of the clients and patients you’ve worked with.
One of the challenges of “picky eating” (which may also be referred to as fussy eating) and which can further present as an element of the diagnosis of ARFID - Avoidant/Restrictive Food Intake Disorder1 - is discerning whether it most represents the formation of a cemented and largely unexamined pattern of dietary behaviour over time or whether it better represents an underlying psychological disorder. Of note here is that ARFID frequently occurs with other conditions, such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) and that a fear response is often involved when presented with particular foods. Furthermore, ARFID is most prevalent in children, so the presence of picky eating in adults is much less likely to be a sign of ARFID.
The clients that I have seen with picky eating behaviour have often had a history of feeling “badgered” about their eating (sometimes by medical and health professionals, sometimes by family members and sometimes going as far back as childhood) and as a consequence have developed an understandable defensiveness and even a “practitioner – induced resistance” to changing their dietary habits.
With health coach training, comes awareness of concepts like the “righting reflex”2, as well as the pitfalls of arguing strongly for change, which tends to evoke “sustain talk”2 rather than “change talk”2 founded in the appreciative exploration of what could be.
In a recently published paper in the American Journal of Lifestyle Medicine3, I argue that health coaching is an efficacious response to non-ARFID picky eating and its frequently observed co-morbidities. Picky eating is not necessarily a benign condition. While little is understood about adult picky eating and its origins, it’s reasonable to conclude from other data that a long term and highly restricted diet, which may be focused on foods of a particular colour, or texture, or flavour profile may result in detrimental metabolic conditions.
A suitably qualified and mindful health coach can begin with an appreciative and empathetic engagement. Although it may seem paradoxical to some, taking the time to understand the ways in which the apparently restricted diet and picky eating behaviour support the person will immediately begin to build and develop the practitioner-client relationship. In my experience, it is uncommon for a client to present with picky eating as the issue or concern they wish to manage. More frequently, people present with a desire for increased well-being, weight loss, reduction in prescribed medication usage or a desire for capacity to do something functional that they currently struggle to do. It’s in this context that information about picky eating behaviour tends to emerge.
The creation of a personal vision for health, or that profound “Why” which fuels motivation, sits at the heart of behavioural change. Trained health coaches, of course, are adept at this “envisioning” and immediately recognise the powerful value of a conversation which begins here, rather than a conversation beginning with attempts to challenge and change picky eating.
While picky eating can be assessed with tools, straightforward open inquiry is every bit as useful in gaining understanding of it. The following inquiries can help to paint a picture of what the person is eating day to day:
What does a typical dinner/breakfast/ lunch look like for you?
What do you eat between main meals?
What new foods have you tried this year?
What vegetables do you routinely eat?
An inquiry such as the following can begin to develop discrepancy for the person about their eating behaviour and their health vision:
What has been the impact of this eating pattern on your overall health, in your view?
Beyond this, a coaching approach which focuses on the whole person and their entire health (not simply picky eating behaviour) almost always leads to an engagement in which the person feels like their needs, values, successes and struggles are understood. This itself forms the foundation of lasting behavioural change. It also addresses the deeply held and often unexpressed fear people have that the practitioner they see is “just going to be another person who tells me what I need to do.”
From this point, working with a client who wishes for improved health and also has a habit of picky eating is broadly similar to working with a person who has a habit of eating “junk food” or a habit of not exercising or staying up late and missing sleep.
A process of moving between the “Why?” (Vision) and the “What and How?” (SMART goals) supports the client to design goals which are personally meaningful and which enable them to make steps towards sustainable health behaviour change.
Use of Motivational Interviewing2 skills, and in particular the Decisional Balance2 tool, can support the client to dispassionately explore the various dimensions of what it may mean to either make a behavioural change or continue as they are, without experiencing judgment for acknowledging that there are down sides to change and there are likely upsides for them to staying the same!
As is the case with practitioners in any discipline, health coaches should remain mindful of scope of practice and if necessary, support the client to liaise with their physician, a psychologist or a social worker who may be able to provide adjunctive treatment.
On the surface, picky eating may appear to present as a difficult clinical challenge. While it may have a more complex and comorbid basis, particularly in children, in adults it is most likely to represent a long-standing habitual pattern of behaviour. When the client is engaged in broadly considering their own vision for health and well-being, the opportunity to co-create multiple pathways to this outcome arises. Many of these pathways will almost certainly involve changes to picky eating behaviour.
RESOURCES 1 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013
2 Miller, William R., and Stephen Rollnick. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press, 2013
3 Matthews, S. Health Coaching as an Intervention for Picky Eaters. American Journal of Lifestyle Medicine. Published online 29 July 2020. Available at: https://doi.org/10.1177/1559827620943821