Mediating effect of food disgust between depression/anxiety and avoidant restrictive eating

Abstract

Introduction

Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder characterized by restrictive eating pattern behavior such as severe picky eating, fear of aversive consequences of eating, and lack of interest in food. Data about the subject is minimal and can be influenced by food disgust and mental health issues like anxiety or depression. Therefore, this research explores whether feeling of disgust towards food help explain the link between ARFID symptoms, anxiety and depression in a group of Lebanese adults.

Methods

This study took place between September and December 2024 using a cross-sectional design. A total of 396 participants (mean age was 28.34 years; 26.5% females) were recruited using a snowball sampling method and completed an online self-administered questionnaire through Google Forms.

Results

The results of the mediation analysis indicate that food disgust partially mediates the association between depression/anxiety and ARFID symptoms. Higher depression and anxiety were highly associated with higher food disgust, whereas increased food disgust was crucially associated with increased ARFID symptoms. Finally, higher levels of depression and anxiety were significantly correlated to greater ARFID symptoms.

Conclusion

The study emphasizes the relationship between food disgust on ARFID symptoms and anxiety in adults. Future research examining the connection between ARFID symptoms and anxiety in adults is essential for gaining deeper insight into the underlying mechanisms and for guiding the development of therapies that effectively target disgust-driven food aversions, and the importance of early emotional screening and individualized treatment to support nutritional rehabilitation.

Plain language summary

This study examined whether food disgust explains the link between anxiety, depression, and Avoidant/Restrictive Food Intake Disorder (ARFID) symptoms. Among 396 Lebanese adults, higher anxiety and depression were associated with greater food disgust, which in turn was linked to more severe ARFID symptoms. These findings suggest that treating food disgust, along with emotional screening and personalized treatment, may improve eating behaviors in individuals with mental health struggles.

Introduction

Avoidant/restrictive food intake disorder (ARFID) is a condition that was recently added to the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders [1]. It is characterized by restrictive eating patterns, such as lack of interest in food, avoidance based on sensory sensitivities, or fear of negative consequences from eating, like choking [1]. Some people with gastrointestinal disorders may also have ARFID symptoms out of fear of experiencing gastrointestinal symptoms after eating [2]. These patterns may lead to significant malnutrition, stunted growth, dependence on supplements and psychosocial impairment [1, 3]. It differs from other eating disorders because it is not motivated by body image concerns or appearance-related pressures, in contrast to conditions like anorexia nervosa or binge eating disorder [3, 4]. Neurobiological theories of ARFID suggest [5] an increased risk for potential psychiatric comorbidities like anxiety and a tendency to maintain food related chronic restrictive eating behavior as seen in ARFID [3, 4]. In clinical settings, ARFID has been linked to dysmorphic concerns [6], difficulties in social and emotional functioning, physical health impairments [7–10] as well as other neuropsychiatric diseases like attention deficit hyperactive disorder or autism [11–13]. Despite increasing evidence of the consequences of ARFID, community-based reports show that the prevalence of ARFID is between 0.3 and 15.5% [14], but those values may be underestimated because of a lack of integration into public healthcare policies.

Depression, anxiety and ARFID symptoms

One of the most common mental comorbidities associated with the onset and persistence of ARFID symptoms is anxiety [11, 15]. People with ARFID frequently exhibit increased susceptibility to anxiety, which often occurs before the eating disorder arises [4, 13, 15]. A distressing event like choking, vomiting, extreme nausea, or undergoing an invasive gastrointestinal procedure like an endoscopy or tube feeding will often set off this subtype. According to current studies these experiences produce a potent conditioned fear response that generalizes to broader eating contexts [16–18]. Also, the internalization of symptoms as seen in depression, where poor emotional regulation and its relationship to altered eating habits predispose individuals to avoidant eating [18]. In ARFID communities, epidemiological studies consistently show significant rates of comorbid depression and anxiety. For example, Kambanis et al. found that 45% of their ARFID sample had a current psychiatric diagnosis, most frequently anxiety, OCD, or trauma-related disorders [19]. Also, according to a JAMA Pediatrics study of 207 children and adolescents with ARFID symptoms, the lifetime prevalence of mental comorbidity was 53%, 10% had co-occurring depression and 49% had co-occurring anxiety, with comorbidity rates rising in older adolescents.

From a neurological standpoint, there is evidence of dysregulation in the brain circuits responsible for processing fear, which supports the association between anxiety and ARFID [20]. According to fear-conditioning models, increased danger perception and resistance to extinction are caused by hyperactivation in the lateral amygdala, which is where sensory input converges [20]. This suggests that individuals with emotional disorders may experience increased sensory alterations, which could contribute not only to ARFID symptoms but also to increased food disgust.

Depression, anxiety and food disgust

Anxiety and depression can shape negative emotional responses toward eating by intensifying emotional reactivity, avoidance tendencies, and poor emotion regulation [3, 4, 21]. Here, disgust functions as a more comprehensive psychological and sensory filter that evaluates and frequently rejects food, rather than just being a response to repulsive stimuli [22, 23]. In fact, findings have shown that food disgust partially mediated the relationship between disordered eating and emotional distress [24]. This suggests that anxiety may influence food avoidance behaviors partly by anticipating disgusting experiences [24, 25]. In addition, patients with anhedonia and impaired sensory processing may experience increased negative reactions to food textures, smells, or appearances, thereby heightening disgust responses. cognitive distortions, such as thinking patterns (e.g., negativity bias) may also amplify perceptions of food as unclean, unhealthy, or dangerous, reinforcing disgust reactions. Importantly, despite their differences, disgust and anxiety and depression are related at a psychological and neurological level [26]. Their relationship is complicated: research suggests that self-reported disgust can rise in response to fear, and that both emotions may be evoked in reaction to perceived danger, particularly when it comes to food [27–29]. We may add, hyperreactivity in the brain areas in charge of anhedonia, interoception and threat detection may be the foundation of sensory intolerance, resulting in excessive reactions to tastes, textures, scents, and physical sensations [30–32].

Food disgust and ARFID symptoms

Disgust is a human reaction that acts quickly as a reflex to protect us from potentially dangerous circumstances. It relies on sensory inputs from the senses, such as smell, taste, and vision [32]. Food disgust, in particular, is associated with avoiding pathogens in food, which may result in restrictive eating patterns [23, 33–35]. Additionally, the food’s consistency and characteristics can occasionally be linked to rejection [22, 33, 36, 37]; however, individual differences may result from cognitive processes, protective mechanisms acquired ontogenetically via personal experiences, and habituation that normalizes certain food culture behaviors [38, 39]. As shown by recent studies, people with ARFID frequently react greater disgust to particular food textures, scents, and appearances, which can result in severe avoidant behaviors [40]. This avoidance, motivated by disgust, could be a reinforcing process that lowers quality of life and causes chronic undernutrition [33]. Furthermore, according to some research, disgust sensitivity is a strong emotional influence on how people perceive and react to food cues and is not only a sign of ARFID [33, 41, 42]. Food disgust may therefore act as a link in the cognitive-emotional process that explains the intensity and severity of ARFID symptoms [21, 41, 42].

The present study

Research examining the psychological and cultural aspects of ARFID symptoms in Arab nations is remarkably lacking, despite the disorder receiving more attention in Western communities. The Arab world has distinct cultural, religious, and societal views on food compared with the West, making it important to conduct research that reflects these specific realities. For instance, food has profound symbolic and communal significance in Arab communities, it is not just a source of nourishment but also a key component of social cohesiveness, hospitality, and religious ritual [43, 44]. As a result, people with ARFID who limit their food intake may experience both personal impairment and cultural conflict, especially in environments where sharing food and eating meals together are practiced behaviors or traditions within a society [45, 46]. However, this cultural diversity today coexists with elevated levels of stress, increased mental health issues, and widespread economic instability, all of which may increase the likelihood of disordered eating habits [47]. In addition, the stigma associated with mental illness is still very much present in Lebanese society, which makes it more difficult to diagnose and treat conditions like ARFID [48].

Therefore, this study aimed to examine whether food disgust sensitivity mediates the link between ARFID symptoms and emotional distress among Lebanese adults [49, 50]. Although food disgust has been recognized as a mechanism connecting internalizing symptoms and avoidant eating in Western settings [51–53], little is known about its role in Arab contexts [49, 50]. By addressing this gap, our study provides culturally relevant insights into the interplay between food disgust, ARFID symptoms and mental health.

Methods

Study design and participants

This cross-sectional study was conducted between September and December 2024, using a snowball sampling technique [54]. The survey was first developed on Google Forms, after which an initial group of participants who met the inclusion criteria and provided consent was invited to complete it. These participants were then asked to refer eligible contacts, who in turn recommended additional individuals, creating a chain of referrals. Recruitment continued until no new participants emerged and data saturation was achieved, with all participants receiving the same study information and consent procedures to ensure consistency and ethical standards. The survey link was distributed through social media and messaging platforms (WhatsApp, Instagram, Messenger, and email). Every respondent took part in the study voluntarily and without compensation. Participation was open to all individuals over the age of 18. Individuals who fully declined to participate and those younger than 18 years old were excluded from the study, as well as pregnant women because pregnancy alters a woman’s appetite, metabolism, nutrient requirements, and eating patterns to support fetal development [55].

Minimal sample size calculation

Based on the formula proposed by Fritz and MacKinnon [56] , where f = 0.14 for small effect size, L = 7.85 for a 5% alpha error and statistical power of 80%, and k = 3 variables that would be involved in the mediation model, a minimum of 404 participants was necessary for this study.

Questionnaire

On average, participants took about fifteen minutes to complete the Arabic version of the questionnaire. Sex, age, marital status, and the Household Crowding Index (HCI) [57], were among the sociodemographic data collected in the first section. A higher index score indicates a lower socioeconomic status of the family. The physical activity index [58] was determined by multiplying the intensity, frequency, and duration of physical activity.

The nine item avoidant/restrictive food intake disorder screen : (NIAS)

This scale was designed to screen for ARFID symptoms, and validated in Arabic [59]. It consists of 9 items, scored on a 6-point Likert scale, “Strongly disagree,” “Disagree,” “Slightly disagree,” “Slightly agree,” “Agree,” and “Strongly agree” [60], and includes three subscales. It consists of three subscales composed of 3 items each as follows: Picky eating, Appetite and Fear. Higher scores indicate more avoidant/restrictive eating. It has been suggested to use cutoff values of ≥ 10, ≥ 9, and/or ≥ 10 to identify those who meet the NIAS dimensions Picky eating, Appetite, and Fear, respectively [61].

Generalized anxiety disorder (GAD-7)

It is a short, self-administered questionnaire consisting of 7 items, developed to screen for symptoms of Generalized Anxiety Disorder experienced over the past 2 weeks. Items are rated on a 4-point scale each, ranging from 0 to 3 [62]. Higher scores reflect higher levels of anxiety. It is validated in Arabic, showing strong psychometric properties across different populations [62, 63].

Patient health questionnaire (PHQ9)

The PHQ-9 [64], previously validated in Arabic [65], includes 9 items to screen for major depressive disorder by evaluating the persistence the occurrence of symptoms over the previous 2 weeks. Each item is rated on a 4-point scale from 0 (Not at all) to 3 (Nearly every day). Higher scores indicate more severe symptoms of depression.

Food disgust scale

Eight items make up the short version of the Food Disgust Scale, and each one represents a distinct domain of disgust related to food [66]. The scale asks participants to rate how disgusting they find various food-related situations, using a 6-point scale from 1 (not disgusting at all) to 6 (extremely disgusting). Originally created and approved in German, the FDS-short has also been successfully adapted and validated for use in Arabic-speaking populations [67].

Self-disgust scale

The Self-Disgust Scale (SDS) is a 12-item instrument that assesses self-directed disgust across two main components: disgust related to personal characteristics and behavior, and disgust related to appearance and self-perception; offering insight into how individuals evaluate both their inner qualities and outward presentation [68]. The scale has not yet been validated in Arabic. Items are rated on a 7-points Likert scale ranging from strongly disagree to strongly agree, with higher scores indicating greater levels of self-disgust.

Statistical analysis

Data analysis was performed using SPSS software version 27. The normality of the distribution of the ARFID symptoms scores was confirmed by calculating the skewness and kurtosis; skewness and kurtosis values between − 1 and + 1 are considered acceptable to prove a normal univariate distribution. To compare two means, the student’s t-test was used, and the Pearson test is used to compare two quantitative variables. Mediation analysis was conducted using Model 4 of the PROCESS macro (version 3.4) in SPSS. The analysis used 5,000 bootstrap samples and a 95% confidence interval. This approach generated four key pathways: Path A that links the independent variable to the mediator, Path B linking the mediator to the dependent variable, and Paths C and C′ representing the total and direct impacts of the independent variable on the dependent variable, respectively. Mediation was deemed statistically significant when the confidence interval did not include zero. Covariates included in the model were those that had a p < 0.250 in the bivariate analysis, while p < 0.05 was considered statistically significant.

Results

Participants

The questionnaire was completed by a total of 396 participants, with a mean age of 28.34 years old, and 26.5% females, with a mean NIAS score of 13.76 and 33.8% of them showing ARFID symptoms. All participant characteristics can be found in Table 1.

Table 1.

Sociodemographic and other characteristics of participants (N = 396)

Variable	N (%)
Gender
Male	291 (73.5%)
Female	105 (26.5%)
Social status
Single, divorced, widowed	326 (82.3%)
Married	70 (17.7%)
Suicidal ideation
No	235 (59.3%)
Yes	161 (40.7%)
Symptoms of picky eating (yes)	78 (19.7%)
Symptoms of appetite (yes)	87 (22.0%)
Symptoms of fear (yes)	39 (9.8%)
NIAS symptoms
0	262 (66.2%)
1	82 (20.7%)
2	34 (8.6%)
3	18 (4.5%)
	Mean ± SD
Age (years)	26.26 ± 8.18
Household crowding index	1.00 ± 0.55
Financial burden	5.47 ± 2.60
Physical activity	28.10 ± 22.15
Nine-item ARFID screen score	13.76 ± 9.85
Anxiety (GAD-7)	7.83 ± 5.52
Depression (PHQ-9)	10.62 ± 6.67
Food disgust	27.15 ± 6.67
Self-disgust	30.90 ± 14.55

ARFID  Avoidant/Restrictive Food Intake Disorder

Bivariate analysis

Being single, divorced, widowed vs. married was strongly linked with increased NIAS scores (Table 2). Moreover, older age and higher physical activity were notably associated with lower NIAS scores, whereas higher depression, anxiety, food disgust and self-disgust were substantially correlated with higher NIAS scores (Table 3). Higher self-disgust was significantly linked to higher picky eating (r = 0.36; p < 0.001), appetite (r = 0.21; p < 0.001) and fear (r = 0.20; p < 0.001).

Table 2.

Comparison of NIAS scores between different sociodemographic variables (gender and social status)

Variable	Mean ± SD	P	Effect size
Gender		0.141	0.168
Male	13.32 ± 9.80
Female	14.97 ± 9.95
Social status		0.023	0.301
Single, divorced, widowed	14.28 ± 9.70
Married	11.33 ± 10.21

Numbers in bold indicate significant p values

Table 3.

Pearson correlation matrix

	1	2	3	4	5	6	7	8
1. Avoidant/Restrictive Food Intake Disorder symptoms	1
2. Age	− 0.13**	1
3. Household crowding index	0.01	− 0.13*	1
4. Financial burden	− 0.03	0.26***	0.06	1
5. Physical activity	− 0.10*	− 0.04	− 0.03	0.01	1
6. Depression	0.35***	− 0.14**	0.01	0.13**	− 0.14**	1
7. Anxiety	0.33***	− 0.11*	− 0.04	0.13**	− 0.11*	0.81***	1
8. Food disgust	0.32***	− 0.004	− 0.06	0.09	− 0.09	0.18***	0.18***	1
9. Self-disgust	0.22***	− 0.17***	0.06	0.06	− 0.13**	0.63***	0.53***	0.10

*p < 0.05; ***p < 0.01; ***p < 0.001

Analysis of mediation with ARFID symptoms scores considered as the dependent variable

When modifying the mediation analysis results, the following factors were considered: gender, social status, age, and physical activity. Food disgust partially mediated the association between depression disorder (indirect effect: Beta = 0.06; Boot SE = 0.02; Boot 95% CI 0.02, 0.11) and anxiety (indirect effect: Beta = 0.07; Boot SE = 0.03; Boot 95% CI 0.03, 0.13) with ARFID symptoms. Higher depression and anxiety were crucially associated with higher food disgust, whereas higher food disgust was markedly associated with increased ARFID symptoms. Lastly, increased depression and anxiety were strongly linked with greater ARFID symptoms (Figs. 1 and 2). The overall R² value of the depression model was 0.203 whereas that of the anxiety model was 0.189, indicating that 20.3% and 18.9% of the variance in ARFID symptoms are explained by food disgust (medium effect) respectively.

Fig. 1.

a Relation between depression and food disgust (R² = 0.054); b Relation between food disgust and avoidant/restrictive food intake disorder symptoms (R² = 0.203); cTotal effect between depression and avoidant/restrictive food intake disorder symptoms (R² = 0.139); c' Direct effect between depression and avoidant/restrictive food intake disorder symptoms. ***p < 0.001

Fig. 2.

a Relation between anxiety and food disgust (R² = 0.051); b Relation between food disgust and avoidant/restrictive food intake disorder symptoms (R² = 0.189); c Total effect between anxiety and avoidant/restrictive food intake disorder symptoms (R² = 0.122); c' Direct effect between anxiety and avoidant/restrictive food intake disorder symptoms. ***p < 0.001

On the other hand, self-disgust did not mediate the association between depression (indirect effect: Beta = -0.01; Boot SE = 0.06; Boot 95% CI -0.14, 0.12) and anxiety (indirect effect: Beta = 0.05; Boot SE = 0.06; Boot 95% CI -0.06, 0.17) with ARFID symptoms.

Discussion

This study seeks to investigate the mediation of food disgust between ARFID symptoms, anxiety and depression among Lebanese adults. Food disgust partially mediated the relationship between depression and anxiety and ARFID symptoms, with higher emotional distress linked to greater food disgust, which was associated with increased restrictive eating symptoms.

Anxiety/depression and ARFID symptoms

The study showed a significant association between ARFID manifestations and symptoms of both anxiety and depression. Participants with higher scores of anxiety and depression also showed elevated ARFID symptoms scores, suggesting that internalizing psychopathology is essential for developing and maintaining ARFID symptoms [24, 26].

From a clinical standpoint, ARFID has traditionally been viewed as distinct from other eating disorders due to the absence of body image disturbance or concerns about weight and shape [4]. Findings from our study align with data from recent clinical and community samples. For example, Kambanis et al. found that youth with ARFID symptoms exhibited higher levels of generalized anxiety and depressive symptoms compared to age-matched controls, and these emotional symptoms significantly predicted greater food avoidance behaviors [19, 69]. Similarly, other studies have shown that children and adolescents diagnosed with ARFID were more likely to have concurrent anxiety and depressive disorders, with anxiety emerging as the most prevalent comorbidity [5, 8, 9, 69]. The presence of internalizing symptoms was also associated with greater feeding-related impairment and more treatment-resistant courses [10, 11]. Moreover, additional research has demonstrated the bidirectional relationship between anxiety/depression and feeding difficulties. For example, Zucker et al. examined emotional functioning over time in children at risk for ARFID symptoms and found that elevated anxiety symptoms at age 5 predicted restrictive eating behaviors at age 7, suggesting a prospective link between affective dysregulation and eating pathology [70]. In the reverse direction, chronic food restriction and eating-related social impairment may also contribute to increased social withdrawal, low mood, and anxiety about eating in public, thereby reinforcing internalizing symptoms [71, 72].

At the neurophysiological level, amygdala and insular cortex contributes to heightened fear and disgust responses to food in ARFID. Persistent avoidance behaviors are further reinforced by reduced hippocampus function and impaired regulation by the medial prefrontal cortex. Furthermore, serotonin and dopamine dysregulation, as observed in depression, affects both mood and appetite, while long-term stress impacts the HPA axis, influencing eating habits and reinforcing restrictive intake [73, 74].

Anxiety/depression and food disgust

The present study revealed that anxiety and depression were moderately and significantly correlated with increased food disgust. Results indicate that affective disturbances may contribute to increased disgust reactivity toward food-related stimuli. In certain individuals, especially those with underlying emotional dysregulation, this adaptive emotion may become generalized or exaggerated, leading to heightened sensitivity and avoidance responses even in the absence of real threat [75]. These findings are consistent with the literature, associating affective disorders with increased food disgust sensitivity. Recent research found that individuals with elevated anxiety scores reported significantly more disgust reactions to food images, particularly involving contamination cues, compared to individuals with lower anxiety levels [75]. Similarly, a study of individuals with major depressive disorder found heightened activity in the insula and amygdala when exposed to food-related disgust stimuli, suggesting that mood disorders may sensitize individuals to disgust elicitors at both psychological and neurobiological levels [76, 77]. Additionally, both anxiety and depression are characterized by attentional bias toward negative or threatening information. In relation to food, this may manifest as increased sensitivity to contamination, excessive focus on minor imperfections, and a tendency to interpret ambiguous things as disgusting [78, 79]. Depression, in particular, is associated with a general negativity bias and reduced reward responsiveness, which may amplify aversive responses and positive associations with eating [79, 80]. On the other hand, people with anxiety or depression may be more sensitive to food disgust because of cultural norms. In some cultures, strict rules about food hygiene and appearance shape what has seen as acceptable [80]. Those with internalizing symptoms may take these rules more seriously, seeing slight changes in food as disgusting or unsafe, which may make them more anxious or uncomfortable around food. When food aversion and emotional symptoms co-occur together, developmental paths must also be considered. Childhood and adolescence are critical periods for the formation of both food preferences and emotional regulation. Research by Rozin et al. suggests that disgust sensitivity peaks during childhood and may decrease with age [17]. However, in individuals with persistent anxiety or depression, this decline may not occur. In fact, elevated trait disgust in childhood has been associated with the later emergence of internalizing disorders, pointing to a potential bidirectional relationship [10, 12, 81, 82].

Food disgust and ARFID symptoms

The present study offers strong evidence for a substantial positive correlation between food disgust and ARFID symptoms. This finding underscores that ARFID symptoms are not merely a set of maladaptive eating behaviors but are also shaped by emotional and sensory experiences [25, 70]. This is consistent with recent studies proposing a sensory sensitivity phenotype of ARFID symptoms, in which food rejection is based largely on sensory attributes and the disgust they provoke [4, 25, 78, 83, 84]. Furthermore, children and adults with ARFID symptoms have been shown to display greater food-related disgust sensitivity compared to healthy controls, with disgust responses predicting restrictive eating even beyond other psychological traits such as anxiety or obsessive-compulsive tendencies [79]. Together these findings suggest that disgust is not only a consequence of avoidance but also an important trigger actively shaping dietary behavior [85]. The mechanisms through which food disgust contributes to ARFID symptoms are both psychological and neurobiological [15]. Neuroimaging studies have shown that disgust-inducing food stimuli activates the anterior insula, a brain region involved in interoception, taste processing, and emotional salience. In individuals with ARFID, this neural pathway may be hypersensitive, producing an exaggerated perception of disgust in response to otherwise benign foods [15, 34]. This hyperreactivity may explain the physical symptoms often reported by individuals with ARFID, such as retching and somatic discomfort when confronted with certain foods [30, 31]. These reactions reinforce avoidance behaviors, making exposure to new or previously rejected foods increasingly difficult over time [80]. Cultural factors also shape food disgust responses and should be considered when interpreting ARFID symptoms. In the Arab world, social norms regarding hygiene, preparation, and communal eating practices may heighten sensitivity to specific food stimuli [28, 29, 46, 86]. In Lebanon, traditional culinary practices and family rituals can reinforce food-related disgust, interacting with individual susceptibility to increase the risk or persistence of ARFID symptoms, especially where deviation from accepted food norms is stigmatized [46, 48, 86].

Clinical implications

The study’s conclusions have significant clinical consequences, especially in the diagnosis and management of individuals with ARFID symptoms who also exhibit high food disgust sensitivity and comorbid anxiety or depression. The mediation findings underscore the central role of food disgust as a key mechanism linking internalizing symptoms to ARFID features, highlighting that anxiety and depression are not only independently associated with ARFID symptoms but also indirectly contribute through heightened disgust sensitivity. This suggests that treating mood symptoms alone may be insufficient if disgust-driven avoidance behaviors remain unaddressed. Clinicians should therefore adopt a comprehensive and multidimensional approach to assessment [57] that includes validated screening tools for internalizing symptoms and food-specific disgust sensitivity. The NIAS screening tool is particularly useful, as it classifies clinically diagnosed ARFID symptoms across distinct subscales with recommended cutoff values for identifying specific presentations. Since patients frequently exhibit symptoms spanning more than one subtype, the use of NIAS subscales can help clinicians determine which presentations are most prominent in a given patient, thereby guiding more precise treatment targets.

A recent study by Zickgraf and Elkins emphasized that disgust-based aversions pose a major barrier to nutritional rehabilitation and must be directly addressed in therapy [7–9, 57]. Conventional exposure therapies may be insufficient for patients with strong disgust reactions, because disgust resists extinction better than anxiety and fear [87]Formatting. Therefore, interventions should incorporate cognitive restructuring of contamination beliefs, sensory desensitization, and motivational strategies shown to increase compliance with aversive but necessary exposures [5, 8, 87]. Adjunctive pharmacotherapy such as SSRIs for anxiety/depression or low-dose olanzapine for severe anticipatory anxiety may also be considered. Moreover, nutritional monitoring is essential, as deficiencies (iron, B12, folate, vitamin D) can worsen mood symptoms, and severe cases may require inpatient refeeding with preferred foods or temporary enteral support [3, 7, 64]. Also, cognitive behavioral therapy for ARFID symptoms [88, 89], which targets sensory avoidance, fear of negative consequences, and low interest in eating, has shown promise when adapted to address comorbid emotional symptoms [90, 91], while early screening for food disgust and anxiety in pediatric populations is critical for prevention [92, 93]. Finally, recognizing individual variability in disgust expression supports a precision psychiatry model [94], aligning treatment goals to focus not necessarily on changing preferences, but on enabling functional food intake despite persistent aversions.

Limitations

There are a few important limitations to this study that should be recognized. First, its cross-sectional design means that exposures and outcomes were collected simultaneously, making it impossible to draw conclusions about causality or the direction of observed relationships. Second, data were gathered using self-completed questionnaires, introducing the risk of misunderstanding or memory related errors. Because the subject matter is delicate, there’s also a risk of social desirability bias, where participants might underreport or misclassify their responses to appear more socially acceptable. The extent and direction of this bias are unclear, but it could have influenced how accurate the observed relationships are. Third, because participants were recruited through snowball sampling, the group likely isn’t random, and we don’t know how many people declined to participate. This approach might have caused consistent differences between those who took part and the wider target population, especially regarding gender and marital status which could affect the findings if they’re linked to key study variables. Fourth, since participants enrolled in the study freely, the study might have disproportionately interested people with particular traits, especially given the sensitive topic. This sampling strategy restricts how broadly the results can be applied. Fifth, the high prevalence of suicidal ideation observed in our sample (40.7%) likely reflects the clinical severity and recruitment context of participants, and therefore may limit generalizability to broader populations. Lastly, other potentially significant characteristics such as childhood circumstances, education, family dynamics, and past psychological conditions were not covered. Additionally, the criteria used to select covariates for the bivariate analysis were relatively lenient (p < 0.25), which could have resulted in either excluding meaningful variables or including non-confounding ones. The robustness of multivariable estimates may be impacted by this method, even though the bias that results is probably minimal.

Conclusion

ARFID is an emerging complex condition often related to elevated levels of food disgust, which can be intensified by anxiety and depression and maintain restrictive eating behaviors. Early emotional disturbances may shape disgust sensitivity, contributing to persistent difficulties while cultural factors influence how food avoidance is expressed and treated. Addressing food disgust directly through techniques that help people rethink negative thoughts and feelings, along with practical strategies like gradual exposure, Exposure and Response Prevention (ERP), or pairing previously unpleasant foods with positive experiences, offers a promising way to ease avoidant eating and support mental well-being. Future research following people over time can help us better understand how these patterns develop and refine prevention and treatment approaches to make them more effective and personalized.

Author contributions

FFR, SO, and SH designed the study; GC drafted the manuscript; SH carried out the analysis and interpreted the results; GC, LAN and MC collected the data; GH and all authors reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent.

Funding

None.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the ethics committee of the Notre Dame des Secours University Hospital. Each participant was provided with a written informed consent while submitting the online form. All methods were performed following the relevant guidelines and regulations of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.