Odor-elicited anxiety-to-eat is heightened and independent of odor liking, intensity, and identification in anorexia nervosa.

The ability of olfactory food cues to evoke reward- and approach-related responses has been extensively studied. However, no prior study has assessed whether food odor cues elicit anxiety-to-eat, which may be directly relevant to food avoidance observed in anorexia nervosa (AN). Given that conditioned anxiety responses to food are a key driver of dietary restriction and persistence of illness in AN, we created a novel olfactory food cue paradigm featuring odors representing higher energy dense (HED) foods, lower energy dense (LED) foods, and nonfoods to assess odor-elicited anxiety-to-eat and olfactory performance in girls and women with AN during acute illness (N=23; ages 14-59 years) and healthy control women (HC; N=34; ages 18-52 years). When analyses were adjusted for current anxiety level, participants with AN reported significantly greater odor-elicited anxiety-to-eat HED and LED foods but not nonfoods relative to HCs, and HED food odors elicited greater anxiety-to-eat than LED food odors with no difference between food and nonfood odors. In the HC group, nonfood odors elicited greater anxiety-to-eat than HED and LED foods. Groups did not differ in perceived odor intensity, liking, or identification across HED, LED, or nonfood categories. Among HCs, greater liking for food odors was associated with lower anxiety-to-eat; however, this relationship was absent in the AN group. These findings indicate that individuals with AN may have heightened odor-elicited anxiety-to-eat in response to food that is not due to differences in olfactory performance or liking or overall anxiety. That odor liking was associated with anxiety-to-eat only in the HC group suggests other mechanisms (e.g., associated energy density or macronutrient content) may influence odor-elicited anxiety-to-eat in individuals with AN.