OARacle Newsletter

Across the lifespan, autistic people are more likely to have a diagnosis of obesity than non-autistic people. For this article, “obesity” refers to the medical diagnosis of an elevated body mass index. It is important to be mindful of variety in preferences related to term use (for example, a preference for “larger body size” instead of “overweight”) and to ask the autistic person for their preferred terms. 

Recent research has also shown that if an autistic adult has obesity, they may also be more likely to have other health concerns like type II diabetes or cardiovascular disease. Health goals related to obesity, like weight loss or improving cardiovascular health, can be difficult for anyone to achieve. For autistic people, food selectivity may be a double whammy that makes reaching health goals related to obesity feel even more out of reach.  

Food selectivity—often described as picky eating—is when someone limits the variety of foods in their diet or is particular about how they eat food. Some examples of food selectivity include:  

• Not eating any foods from a particular food group, like vegetables 

• Only eating one specific brand of a food 

• Preferring foods that are a specific color 

• Avoiding foods with certain textures 

• Not liking to mix foods or have foods touching on the plate 

Depending on how you measure it, anywhere from 30 to 90% of autistic children have food selectivity, higher than the common pickiness seen in about 20% of non-autistic young children. While food selectivity usually resolves for non-autistic children, research has shown that food selectivity can last into adolescence and adulthood for some autistic people. Food selectivity can impact multiple aspects of life, including increasing both family stress and health concerns. 

There are several ways that food selectivity can increase the likelihood of weight gain. First, autistic children with food selectivity tend to prefer energy-dense, high-sugar, high-fat foods like processed foods and sweetened-sugary beverages. In addition, just because the variety of foods is limited, that does not mean that appetite is limited. So even if an autistic child is eating an appropriate amount of food, weight gain can happen more rapidly given the types of foods being eaten. In fact, in a group of autistic children and adolescents with obesity, 56% had food selectivity.  

The Double Whammy of Food Selectivity with Health Goals Related to Obesity

While food selectivity can increase the likelihood of weight gain and other health risks, food selectivity can also make treatment more challenging. Diet modifications are one of the most common lifestyle changes recommended for health goals related to obesity. Medical providers will recommend that people increase their fruit and vegetable intake while decreasing their intake of processed foods. But what if you have food selectivity and there is only one vegetable you can eat without stress? What if your primary source of protein is chicken tenders, but only when they are from a particular brand? It becomes really difficult to change the balance of foods you’re eating when you have such a limited starting point. 

Our research team presented data on this topic at the Annual Meeting for the International Society of Autism Research this month. We asked autistic youth (6-17 years) with obesity and their caregivers about food selectivity as well as health and weight management. In our data, 75% of self-reporting autistic youth with obesity described themselves as a picky eater. Many caregivers reported that food selectivity impacts their child’s health (88%) and weight (90%). Youth themselves also shared that food selectivity impacts their health (64%) and weight (86%).  

Treating Food Selectivity Along with Obesity-Focused Health Goals

Our data also highlighted a really important point. Many caregivers (81%) described food selectivity as a barrier to their child making necessary diet changes for health goals related to obesity, even though most (88%) said their doctors discussed food selectivity in conversations about weight management. In other words, while food selectivity is not being ignored in the context of treatment for obesity in autistic youth, it is still interfering with their ability to meet their health goals.  

For autistic youth with both food selectivity and obesity, treatment for food selectivity may be a linchpin for working toward their health goals. Before diving into the challenge of making dietary changes to promote health, someone might need to learn and build skill for how to eat a new or non-preferred food. Our group’s Building Up Food Flexibility and Exposure Treatment Program could be a fit as a precursor or add-on to obesity-focused treatment programs.  

On a final note, as we and others move forward to address this unmet healthcare need in autistic youth, we must remember to listen carefully to autistic people and their loved ones. A focus on understanding lived experiences and partnering with the autistic community is the approach that will maximize the development of meaningful treatments to enhance health, well-being, and quality of life for autistic people and their families.  

Dr. Kuschner is an assistant professor of psychology in psychiatry at the University of Pennsylvania Perelman School of Medicine and a licensed psychologist at The Children’s Hospital of Philadelphia in the Department of Child and Adolescent Psychiatry and Behavioral Sciences, Center for Autism Research, and Program for Advanced Imaging Research. Dr. Kuschner conducts developmental, neurocognitive, and diagnostic assessments as well as treatment for autistic individuals. Her research focuses on using personalized interventions to support unmet needs for autistic youth in several key areas: (1) personalized stepped care for food selectivity in autistic youth, (2) health and weight management for transition-age autistic youth, and (3) inclusive neuroimaging in autism.