Welcome to Nutrition Stories, our series exploring hot topics in nutrition and dietetics. Today’s guest is Rafaella Galvez, a graduate of the UF Didactic Program in Dietetics (DPD) in the Food Science and Human Nutrition (FSHN) Department at The University of Florida. In this article, Rafaella discusses the challenges of ensuring children with autism spectrum disorder eat balanced, nutritious diets by managing food aversions.

Rafaella: Food aversions are sometimes helpful to stop us from eating potentially unsafe foods, which is why sensory qualities such as smell, texture, and appearance of foods are important to notice before eating. However, children with autism may develop food aversions that make it difficult to consume a well-balanced diet. Parents and caregivers are intimately aware of how challenging it can be for their child to overcome a food aversion, so how can we ease this process and foster a healthy relationship with food?

What to Know About Autism Spectrum Disorder

According to the National Institute of Mental Health, autism spectrum disorder (ASD) is a neurological condition that affects social acuity, learning abilities, and behavior in a manner that can make communication challenging.¹ Current prevalence of ASD is 1 in every 36 children, and causes for this disorder are not entirely known.² As a spectrum disorder, ASD can manifest in many ways, and children with autism may have a range of reactions to stimuli. Due to the social and behavioral implications of ASD, the diagnosis of a child in the family can feel overwhelming. This reaction is understandable.

Ensuring a child with ASD eats a nutritious diet can be challenging. Food aversions may be a source of stress around mealtimes and are thought to originate from sensory sensitivity which is prevalent among children with ASD.³ However, the ability to tolerate a varied diet in childhood helps promote nutritional adequacy, healthy development, and demonstrates a balanced relationship with food. Fortunately, we have plenty of opportunities to promote an enjoyable meal with practice and patience.

There may be an overlap between the development of eating disorders and autistic traits relevant to food aversions stemming from childhood.⁴ Many factors can influence dietary behaviors and responses to food or meals. Therefore, parents and caregivers should use strategies to manage adverse circumstances and encourage a diverse, nutritious diet. These strategies to help mediate food aversions and disordered eating should be discussed and implemented under the supervision of the child’s doctor and a qualified professional such as a registered dietitian nutritionist.

Food Selectivity in Children

Children on the spectrum can exhibit greater food selectivity compared to neurotypical children. Food selectivity is typically paired with sensory hypersensitivity. This behavior is rooted in an aversion of certain flavors, colors, textures, temperatures, packaging, and/or presentation.⁴ As a result, the diet can become extremely limited.

It is not uncommon for children with ASD to feel comfortable with a total of 8-20 dishes or require tasting the food a dozen times before eventually becoming able to eat it.⁵ Such strong rigidity with familiarity extends to food choices, leading to reduced acceptance of new foods and potentially make mealtimes feel chaotic or stressful with changes in routine.

Physical and Dietary Manifestations of Food Aversions

Eating Disorders

Food selectivity is a major driving force in the development of eating disorders. With food aversions leading to specific safe foods, finding a balance between routine or familiarity and freedom or variety can be tricky. Ultimately, promoting exploration of all food groups over time, rather than a coveted list of a few food items, may be helpful to promote tolerance of different stimuli.

While the potential connection is not fully understood, research indicates there may be an association between autistic traits and more severe eating disorder pathology, in addition to a higher prevalence of displayed traits among anorexia nervosa patients.³ If an eating disorder is suspected in your child, please consult your child’s doctor and discuss ways to create an effective support system for your child’s needs.

Obesity

Adding to the complexity of autism, at least 30% of those with ASD are obese.⁶ With a preference over energy-dense food over nutrient-dense foods in childhood, children with ASD may develop eating habits that can contribute to the progression of binge eating disorder if they consume specific “safe foods” in excessive amounts. Furthermore, medications often prescribed to manage behavior may lead to unintentional weight gain. Consequently, those with ASD are at higher risk of developing obesity and metabolic syndromes.⁶

Dietary Modifications for Children with Autism

Healthful Habits

A diet low in processed foods that emphasizes fruits and vegetables can reduce the risk of various chronic diseases and promote overall health. Fruits and vegetables also provide antioxidants and fiber which promote a healthy gut microbiome and may play a role in neurological functioning.⁶

Managing Food Aversions

Ritualistic and repetitive behaviors in children with ASD sometimes contribute to food selectivity. Gradually introduce new foods under the guidance of the child’s doctor. Simply having a new food on the table without expecting the child to eat it can allow the child to feel more comfortable eating that food in the future.

With patience and compassion, parents can observe their child. If possible, they can ask questions to identify certain triggers that contribute to their child’s food aversions. Everyone learns and adapts, the family becomes more attuned to preferences, and the child will benefit in the long run.

Here are a few tips that may be helpful:

(1) Baby steps

Patience during mealtimes is essential. The toll of a meltdown on a parent is undeniable, but this is an opportunity to be creative and learn about your child. Familiarity is okay. Placing a new food item on the same plate as a “safe food” may reduce anxiety to future exposure and aversion over time.

Engage the senses one at a time. Show the child what it means to see, touch, smell, and taste the food by mimicking the behavior you desire them to reflect. Encourage them to give “a kiss” to the food item, then a lick, and then take a bite. This engagement can also serve as a bonding opportunity with your child, further promoting reduced mealtime anxiety.

(2) Playing with new food

Not only is freedom promoted through play, but the child is also able to safely build familiarity with the new food which can lower anxiety during mealtime. Allowing sensory exploration can help encourage the child to feel safer the next time the next time they encounter food. After they seem comfortable with sight, touch, and smell, maybe ask them then if they’d like to taste it. If they say no, crack a joke! “Well, would you like to hear it?”

(3) Modify Textures

The way a food feels in the mouth, rather than flavor, may lead to a food aversion. If a child rejects a food or has trouble chewing related to oro-motor control, they may better tolerate a pureed version. Adopting this practice can help maintain certain food groups in adequate quantities within the diet.

What’s Next?

After reading this article, hopefully you’ve gained a deeper understanding of food aversions and their implications for children with ASD. Remember to aim for progress and not perfection. Depending on your child’s needs, identify one goal or food aversion to work on at a time. Begin with promoting familiarity through sight, touch, and smell before incorporating taste. You can adjust your presentation of food at any time. Always discuss nutritional priorities and potential dietary changes with your child’s doctor before implementing new practices.

References

1. National Institute of Mental Health. Autism spectrum disorder. National Institute of Mental Health. Published February 2023. https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd
2. Centers for Disease Control and Prevention. Data & statistics on autism spectrum disorder. Centers for Disease Control and Prevention. Published April 4, 2023. https://www.cdc.gov/ncbddd/autism/data.html
3. Cermak, S.A., Curtin, C., et al. Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association. 2013;110(2):238-246. Doi: 1016/j.jada.2009.10.032
4. Fithall K, Gray I, Linardon J, et al. Exploring the role of autistic traits and eating disorder psychopathology on mentalising ability in the general population. BMC Psychology. 2023;11(1). doi:https://doi.org/10.1186/s40359-023-01306-z
5. Alibrandi, A., Zirilli A., et al. Food Selectivity in Children with Autism Spectrum Disorder: A Statistical Analysis in Southern Italy. 2024;10(9):1533. doi: 10.3390/children10091553
6. Doreswamy, S., Bashir A., et al. Effects of Diet, Nutrition, and Exercise in Children With Autism and Autism Spectrum Disorder: A Literature Review. Cureus. 2020;12(12):e12222. Doi: 7759/cureus.12222

Header photo credit: Hannah Tasker on Unsplash.

Looking for more posts sharing stories about nutrition hot topics? Check out the rest of the UF/FSHN Nutrition Stories Series!

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