Picky eating, to the extreme

Pizza, pizza, pizza, chicken fingers, pizza, buttered noodles, pizza.

This is a typical week of eating for Corey Fader, 19, an undergraduate at the University of Pennsylvania's Wharton School. An otherwise well-adjusted man with plenty of friends, who also juggles a job at a start-up and loves photography, Fader is a picky eater.

Corey Fader, a University of Pennsylvania sophomore, lives with a strong anxious aversion to almost all foods, typically eating only once per day from a small list of items such as chicken fingers, plain pizza, and ice cream. He supplements his restricted diet with vitamins. Tuesday, July 21, 2015, Philadelphia, Pennsylvania. ( MATTHEW HALL / For the Inquirer )

We all know picky eaters. Most are children. And then there is the occasional adult who takes drastic, sometimes odd, measures with food. Disemboweling sandwiches in an effort to avoid the onions, or picking mushrooms off of pizzas because of the "slime" factor.

Fader is way beyond that.

In 2013, his condition was given a name, recognized by the psychiatric community as avoidant/restrictive food-intake disorder, or ARFID.

"I don't like the term picky eating," Fader said. "Picky eating implies that you can pick what you eat."

Lunching at City Tap House in University City the other day, he didn't look at the menu. He didn't have to. He eats only one thing the restaurant offers. (And he frequents only four restaurants.)

"Can I have a margherita pizza?" he said to the waiter. "With extra fresh mozzarella, no basil, and no shredded cheese on top. No Parmesan or anything like that. Just the fresh mozz. Nothing green on it at all."

For Fader, daily life is a struggle. His relationship with food affects everything from his social life, to his health, to even the act of swallowing.

"When I eat something that is foreign, I automatically throw up," he said. "It's almost all psychological."

When Fader was a child, camp was out - there would be nothing he could eat. He left a Fourth of July barbecue to buy pizza after being asked repeatedly if could eat this or that. And dating is out. How could he take a woman out to eat?

Avoidant/restrictive food-intake disorder is so new that there are no prevalence estimates and few clinicians trained to treat it.

Judy Jackson, a psychotherapist Fader was seeing until last year, when school made it difficult for him to get to her Ardmore office, said she had diagnosed cibophobia - literally, fear of food - but that the new diagnostic term made sense.

Hana Zickgraf, a doctoral student in clinical psychology, was the senior author of a study published in March by researchers at Penn and the Monell Chemical Senses Center that looked at the behaviors and attitudes of adult picky eaters around food. People with the new diagnosis cannot distinguish between what is food and what isn't, Zickgraf said.

"Asking them to eat a food item that they don't view as a food, they see that as the same as asking them to eat a plastic bag."

They respond by choking or gagging, the body's normal reaction to detecting toxins or taking a bite that is too big. But people with the food-intake disorder seem to automatically classify most foods as inedible. As a result, they have a very limited diet, gravitating toward bland choices that tend to be beige or white.

"I go for the ones with less sauce," Fader said, gesturing toward the pizza he was eating. "When I get to the part where there is no more cheese, I'll avoid it." He put down the two inches of saucy crust that was left over from the slice he had been working on. It joined the crust graveyard already on his plate.

Although the eating disorder is believed to be largely psychological, limited evidence suggests that genetics may play a role. Hypersensitivity to tastes and smells may be controlled by genes involved in taste perception.

Fader said that, even as a baby, he had a very sensitive palate. His mother had a hard time breast-feeding him, and she could get him to eat only two baby foods. Now, when he orders chicken fingers from Wawa, he gets them extra crispy.

"The crispier they are, there is not as strong of a taste. Same with the fries," Fader said. "If there are some things that have stronger scents," he said, recalling a table he shared at a restaurant with friends, "I try to sit at the opposite end."

A 2007 study suggests that fear of trying new foods can be passed on from parent to child.

"My dad is a picky eater, too," Fader said, "but he doesn't compare to me."

To be classified as an eating disorder, said Sondra Kronberg, a clinical nutrition therapist and spokeswoman for the National Eating Disorders Association, the behavior must be severe enough to interfere with the quality of life or health or be potentially fatal.

"I run a treatment center with a couple of hundred patients," said Kronberg, who directs the Eating Disorder Treatment Collaborative in Jericho, N.Y. Only a handful have the newly named disorder, she said.

A few news stories have described people who wind up in the hospital from eating the same foods every day, much like Fader, who says he eats only four food items. Those items - pizza, chicken fingers, macaroni and cheese, and buttered noodles - are high in fat and carbohydrates, and nearly devoid of vitamins and minerals.

Yet Kronberg's patients are not necessarily overweight. They can be, but there seems to be no correlation between obesity and avoidant/restrictive food-intake disorder, she said.

"But there is a severe nutritional deficiency. They're not getting enough of what the body needs."

Fader knows that his habits pose a serious threat to his health.

"I don't eat breakfast and only eat once a day. It's one of those things I put off [thinking about]. Like I'm invincible. But I know in the back of my mind that I'm not. I've tried to change. I've never really found something that works."

He said he had tried different outpatient treatments, and even hypnosis.

"I pretty much reached the point where I gave up," he said.

Zickgraf is working under the direction of her adviser, Martin Franklin, an associate professor in psychiatry at Penn, to develop a therapy program for people with ARFID. The treatment uses a cognitive-behavioral approach to overcome patients' deep-set thinking that they cannot swallow the food.

"We tell them that, yes, celery is going to taste terrible, and rather than starting with a tiny bit and working their way up to eating a whole piece, they are learning how to use techniques" - focusing on something other than the food in the mouth, for example - "to swallow things effortlessly," she said. "We're in the really early stages of treating people, but it does seem to be useful."

It is important to understand the disorder's psychological causes and to encourage people who might have it to seek professional help, Zickgraf said.

"People really do have negative views. They think that these people are spoiled or looking for attention."

Said Fader: "It's like telling someone with ADD just pay attention more, just focus. It's just not quite that easy."

For more information about avoidant/restrictive food- intake disorder, or ARFID,

go to: http://bit.ly/1fYXfLV.