What Is ARFID? More Than Just Picky Eating

Avoidant Restrictive Food Intake Disorder

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Are you or someone you know a picky eater? Some extremely picky eaters may have an eating disorder, known as Avoidant/Restrictive Food Intake Disorder (ARFID). In most cases, picky eating does not interfere with weight status, growth, or daily functioning. However, people who experience consequences such as these as a result of extremely picky eating may need treatment.

Picky eaters are people who avoid many foods because they dislike their taste, smell, texture, or appearance.

Picky eating is common in childhood, with anywhere between 13 percent and 22 percent of children between three and eleven years of age being found to be picky eaters at any given time. While most young children outgrow their pickiness, between 18 percent and 40 percent continue to be picky into adolescence.

Distinguishing ARFID From “Normal Picky Eating”

In developing children, the range of types, textures, and amount of food eaten generally progresses until age six or seven. At around this age, many school age children become more “picky” and start to favor carbohydrates, which fuel growth. Usually by puberty, both appetite and eating flexibility increase, accompanied by a return to a wider range of intake and greater balance within and across meals. Many parents report concern around their child's eating at a young age, but are told by others it is “normal” and not to worry about it.

Parents of children with ARFID often notice challenges in their child’s range of intake as early as 1 year of age.

These children may show a strong preference for a narrow range of foods and may refuse to eat anything outside this range. Parents often report that their children with ARFID had trouble transitioning to mixed foods from single baby foods. They also often report they had a specific sensitivity to textures such as “mushy” or “crunchy.”

It can be hard for parents and health professionals to distinguish “normal pickiness” in a child from a diagnosis of ARFID. Eating behaviors and flexibility may exist on a continuum between those who are adventurous in trying new foods and those who prefer a routine diet. Most children are still able to meet their nutritional needs despite some pickiness.

According to Dr. Fitzpatrick and colleagues, “While many children do express food preferences and many will have strong aversions to certain foods,” ARFID “is distinguished by a refusal to try something new and, therefore is a much more extreme and clinically concerning version of a ‘boring’ eater.” ARFID is described by some as “food neophobia,” where a difficulty with novelty leads to a limited diet.

ARFID: a New Feeding and Eating Disorder in DSM-5

ARFID is a new diagnosis that was introduced with the publication of the Diagnostic and Statistical Manual, 5th Edition (DSM-5) in 2013. Prior to this new category, individuals with ARFID would have been diagnosed as eating disorder not otherwise specified (EDNOS) or fall under the diagnosis of feeding disorder of infancy or childhood. As a result, ARFID is not as well-known as anorexia nervosa or bulimia nervosa.

Even so, it can have serious consequences.

Individuals with ARFID do not eat enough to meet their energy and nutritional needs. However, unlike individuals with anorexia nervosa, people with ARFID do not worry about their weight or shape or becoming fat and do not restrict their diet for this reason. ARFID also does not typically emerge after a history of more normal eating as do anorexia nervosa and bulimia nervosa. Individuals with ARFID usually have had restrictive eating all along.

To meet criteria for ARFID, the food restriction cannot be explained by lack of food, a culturally sanctioned practice (such as a religious reason for dietary restriction), or another medical problem that if treated would solve the eating problem.

Furthermore it must lead to one of the following:

  • Significant weight loss (or failure to make expected weight gain in children)
  • Significant nutritional deficiency
  • Dependence on tube feeding or oral nutritional supplements
  • Difficulty engaging in daily life due to shame, anxiety or inconvenience

Who Gets ARFID?

We do not have good data about prevalence rates of ARFID. It is relatively more common in children and young adolescents, and less common in older adolescents and adults. Nonetheless it does occur throughout the lifespan and affects all genders. Onset is most often during childhood. Most adults with ARFID seem to have had similar symptoms since childhood. If ARFID onset is in adolescence or adulthood, it most often involves a negative food-related experience such as choking or vomiting.

One large study (Fisher et al., 2014) found that 14 percent of all new eating disorder patients who presented to seven adolescent-medicine eating disorder programs met criteria for ARFID. According to this study, the population of children and adolescents with ARFID is often younger, has a longer duration of illness prior to diagnosis, and includes a greater number of males than the population of patients with anorexia nervosa or bulimia nervosa. Patients with ARFID on average have a lower body weight and therefore are at a similar risk for medical complications as patients with anorexia nervosa.

Patients with ARFID are more likely than patients with anorexia nervosa or bulimia nervosa to have a medical condition or symptom. Fitzpatrick and colleagues note that ARFID patients are more frequently referred from gastroenterology than patients with other eating disorders are. They are also likely to have an anxiety disorder, but less likely than those with anorexia nervosa or bulimia nervosa to have depression. Children presenting with ARFID often report a high number of worries, similar to those found in children with obsessive-compulsive disorder and generalized anxiety disorder. They also commonly express more concerns around physical symptoms related to eating, such as an upset stomach.

Types of ARFID

DSM-5 gives some examples of different types of avoidance or restriction that may be present in ARFID. These include restriction related to an apparent lack of interest in eating or food; sensory-based avoidance of food (e.g., the individual rejects certain foods based on smell, color, or texture); and avoidance related to feared consequences of eating such as choking or vomiting, often based on past negative experience.

Fisher and colleagues suggested six different types of ARFID presentation with the following prevalence rates among their sample:

  • Picky eating since childhood (28.7 percent)
  • Having generalized anxiety disorder (21.4 percent)
  • Having gastrointestinal symptoms (19.4 percent)
  • Fears of eating due to fears of choking or vomiting (13.1 percent)
  • Having food allergies (4.1 percent)
  • Restrictive eating for “other reasons” (13.2 percent)

Dr. Bermudez proposed five different categories of ARFID:

  • Avoidant individuals refuse food based on negative or fear-based experiences such as choking, nausea, vomiting, pain, or swallowing.
  • Aversive individuals accept only limited foods based on sensory features. They may have a sensory processing disorder.
  • Restrictive individuals are those who do not eat enough and show little interest in eating. They may be picky, distractible and forgetful, and wish they would eat more.
  • Mixed type includes features of more than one of avoidant, aversive, and restrictive types. The individual usually presents with features of one category first but then acquires additional features from another type.
  • ARFID “Plus” individuals present with one of the ARFID types initially, but then start to develop features of anorexia nervosa such as weight and shape concern, negative body image, or avoidance of more calorically dense foods.

Assessment of ARFID

Because ARFID is a less well-known disorder, health professionals may not recognize it and patients may experience delays in getting diagnosed and treated. A diagnosis of ARFID requires a thorough assessment that should include a detailed history of feeding, development, growth charts, family history, past attempted interventions, and complete psychiatric history and assessment. Other medical reasons for the nutritional deficits need to be ruled out.

Rachel Bryant-Waugh has outlined a diagnostic checklist for ARFID to facilitate gathering the appropriate information:

  1. What is current food intake (range)?
  2. What is current food intake (amount)?
  3. How long has the avoidance of certain foods or the restriction in intake been occurring?
  4. What is current weight and height and has there been a drop in weight and growth percentiles?
  5. Are there signs and symptoms of nutritional deficiency or malnutrition?
  6. Is intake supplemented in any way to ensure adequate intake?
  7. Is there any distress or interference with day to day functioning related to the current eating pattern?

Treatment of ARFID

For patients and families, ARFID can be extremely challenging. Families often get anxious when children are having difficulty eating and may get stuck in power struggles over food. For older adolescents and adults, ARFID can impact relationships as eating with peers can become fraught.

Left untreated, ARFID will rarely resolve itself. The goals of treatment are to increase the patient’s flexibility when presented with non-preferred foods and to help them to increase their variety and range of intake of foods to satisfy their nutritional needs. Many patients with ARFID tend to eat the same food repeatedly until they tire of it and then refuse to eat it again. Thus, patients are encouraged to rotate presentations of preferred foods as well as gradually introduce new foods.

At present, there are no evidence-based treatment guidelines for ARFID. Depending on the severity of the malnourishment, some patients with ARFID may need higher levels of care, such as residential treatment or medical hospitalization, sometimes with supplemental or tube feeding.

After the patient has been medically stabilized, treatment for ARFID often includes teaching anxiety management skills accompanied by the gradual introduction of new foods through “food chaining”: starting with foods that are very similar to foods that they already eat and progressing slowly towards more dissimilar foods. The average person typically requires several presentations before foods are no longer experienced as novel. For people with ARFID, it is often fifty times before a food is no longer experienced as unfamiliar.

For example, one adult patient with ARFID ate no raw vegetables and no fruit. His goals were to increase his ability to eat fruit and vegetables. He did eat carrots when they were in soup. Thus, treatment began by his boiling carrots in chicken broth and cutting them into extremely small pieces and eating those. Next, he started to eat bigger pieces of carrots boiled in broth and eventually carrots just boiled in water. Then, he began to work on peels of fresh carrots.

He also started to work on fruit. He began with strawberry jelly on toast, which was something he was comfortable eating. He next introduced strawberry jelly with seeds to get him used to some texture. After that, he introduced macerated fresh strawberries (mixed with sugar to soften them). Eventually, he began to eat very small pieces of fresh strawberries. After that, other fruits and vegetables were gradually added in a similar fashion.

For children and adolescents with ARFID, there is evidence to believe that Family-Based Treatment, which has strong support for the treatment of anorexia nervosa in young people, can also be successfully applied.

If you (or someone you know) is showing signs of ARFID, it is advisable to seek help from a professional who is well-versed in eating disorders.

Sources

Bermudez, O, Easton E, and Pikus C, “ARFID: Avoidant/Restrictive Food Intake Disorder: An In-Depth View,” Keynote Presentation at the International Association for Eating Disorder Professionals Symposium, March 25, 2017, Las Vegas.

Bryant-Waugh, R. 2013. “Avoidant Restrictive Food Intake Disorder: An Illustrative Case Example.” International Journal of Eating Disorders 46 (5): 420–23. doi:10.1002/eat.22093.

Fisher, MM., Rosen DS, Ornstein RM, Mammel KA, Katzman DK, Rome ES, et al, 2014. “Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A ‘New Disorder’ in DSM-5.” Journal of Adolescent Health 55 (1): 49–52. doi:10.1016/j.jadohealth.2013.11.013.

Fitzpatrick, KK, Forsberg SE, and Colborn D. 2015. “Family-Based Therapy for Avoidant Restrictive Food Intake Disorder: Families Facing Food Neophobias.” In Family Therapy for Adolescent Eating and Weight Disorders: New Applications, edited by Katherine L. Loeb, Daniel Le Grange, and James Lock, 256-276. New York: Routledge.

Nicely, TA., Lane-Loney S, Masciulli E, Hollenbeak CS, and Ornstein RM. 2014. “Prevalence and Characteristics of Avoidant/restrictive Food Intake Disorder in a Cohort of Young Patients in Day Treatment for Eating Disorders.” Journal of Eating Disorders 2: 21. doi:10.1186/s40337-014-0021-3.

Zickgraf, HF., Franklin ME, and Rozin P. 2016. “Adult Picky Eaters with Symptoms of Avoidant/restrictive Food Intake Disorder: Comparable Distress and Comorbidity but Different Eating Behaviors Compared to Those with Disordered Eating Symptoms.” Journal of Eating Disorders 4: 26. doi:10.1186/s40337-016-0110-6.

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