Written by Registered Dietitian Nishti
ARFID stands for avoidant restrictive food intake disorder and is classified as an eating disorder according to DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). The hallmark of ARFID is a disturbance in eating or feeding patterns without fear of weight gain, or a drive for thinness or body dysmorphia, that are characteristic of other eating disorders such as anorexia nervosa. ARFID is characterised by persistent avoidance or restriction of food intake which significantly affects the nutritional intake of children or adults.
Below is an overview of the diagnostic criteria for ARFID.
|Diagnostic criteria for ARFID according to DSM-V:
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
– Significant nutritional deficiency.
– Dependence on enteral feeding or oral nutritional supplements.
– Marked interference with psychosocial functioning.
The eating disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.
When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
Are all people with ARFID underweight?
One of the diagnostic criteria for ARFID is significant weight loss. However, not all children or adults with ARFID are underweight. Some research shows that up to 82% of patients with ARFID have normal weight and some even may be overweight.
Children and adults with highly selective diets who are not underweight might be less likely to be recognised as potentially having ARFID. It is therefore important to understand that having ARFID doesn’t necessarily mean being underweight.
What causes ARFID?
The causes of ARFID include genetic, psychological, and social-cultural factors, as well as biological factors. However, recently, genetics has become a hot topic in ARFID.
Some research has looked at heritability measures of traits related to ARFID presentation.
For example, research on twins shows the following:
- There is a genetic influence on our preference for fruit, vegetables, and protein but not for dairy and snacks. In simple terms, genes influence whether we like vegetables or fruits but genes don’t influence our liking for snacks or dairy since this is a learned behaviour. The same goes for our preferences for desserts, this is also a learned behaviour and not explained by genetics.
- Food fussiness or fear of new foods (neophobia) may be caused by our genetics also.
ARFID and Comorbid disorders
Children with ARFID more commonly have comorbid disorders such as Autism Spectrum Disorder (ASD), Anxiety Disorder, and Food Allergies.
- The eating patterns seen in children with ASD and ARFID share similarities. Sensory sensitivities heightened anxiety around food and eating situations, and a lack of interest in food.
- Research suggests that there is an overrepresentation of ASD in children with an eating disorder, meaning that ASD is common in children with an eating disorder. According to Farag et al. 2022, up to 60% of children with ARFID also have ASD. The manual of mental disorders recognises that ASD is common in individuals with ARFID. Therefore, suspicion of ASD must be raised if you or your child have ARFID or if you are a healthcare professional working with children who have ARFID.
- In a study by Fisher et al (2014) among 98 patients who met the diagnostic criteria for ARFID, anxiety disorder was present in 60% of patients. Heightened anxiety is common in ARFID.
- A recent systematic review showed that the prevalence of an eating disorder in patients with a food allergy ranges from 0.8% to 62.9%, suggesting that food allergy-related distress may lead to an eating disorder, including ARFID.
ARFID is a psychiatric disorder in which individuals present with avoidance of certain foods or categories of food resulting in a diet that is limited in variety, and/or restriction of overall intake resulting in a diet that is limited in volume. One of the most common reasons for avoidance and restriction is a heightened sensitivity to the sensory properties of food such as taste, texture, appearance, and smell, and often a low or complete avoidance of fruits and vegetables.
In turn, these individuals frequently rely on highly processed energy-dense foods and food beige in colour such as chips, chicken nuggets, and white bread, and may therefore have significant deficiencies in vitamins, minerals, and healthy fats. Below is a representation of the 3 types of ARFID.
Food-related trauma and ARFID
Individuals with ARFID may also exhibit food avoidance or restriction due to a fear of aversive consequences, such as a fear of choking, vomiting, or gastrointestinal pain. Often these individuals have experienced a food-related trauma and subsequently begin avoiding certain foods to guard against another negative experience. Their food avoidance may generalise beyond the trigger food to similar foods, then to entire food groups, and in some of the most severe cases, avoidance of all solid foods, requiring nutrition support-related interventions.
More than a Picky Eater
A patient with ARFID is more than ‘just’ a picky eater. There is no agreement on a formal definition of picky eating but it is generally defined as occurring in children who are normal weight but consume an inadequate variety of foods through rejection of foods that may either be familiar or unfamiliar to them. It is a common behaviour in early childhood but it generally resolves with minimal or no intervention by healthcare professionals.
Treatment of ARFID
The treatment of ARFID requires a range of specialists from a dietitian to a psychologist and an occupational therapist. The dietitian will help address nutritional concerns, a psychologist can assist with cognitive behavioural therapy for example, or other forms of therapy and an occupational therapist may assist with feeding and sensory concerns. A psychiatrist may also be required if medication is needed. The treatment for ARFID includes:
- Cognitive behavioural therapy, family-based therapy.
- Food exposure such as the 6 steps to eating model
- Food chaining
ARFID is an eating disorder characterised by persistent avoidance or restriction of food intake but individuals display no body image issues. ARFID significantly affects the nutritional intake of children and therefore a dietitian plays an important role in managing these patients.
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Diagnostic and Statistical Manual of Mental Disorders: DSM 5, (5th edition) Washington DC: American Psychiatric Association; 2013.
Brigham KS, Manzo LD, Eddy KT, Thomas JJ. Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Curr Pediatr Rep. 2018;6(2):107-113
Taylor CM, Emmett PM. Picky eating in children: causes and consequences. Proc Nutr Soc. 2019;78(2):161-169.
Seetharaman S, Fields EL. Avoidant/Restrictive Food Intake Disorder. Pediatr Rev. 2020;41(12):613-622. doi:10.1542/pir.2019-0133
Nickel K, Maier S, Endres D, et al. Systematic Review: Overlap Between Eating, Autism Spectrum, and Attention-Deficit/Hyperactivity Disorder. Front Psychiatry. 2019;10:708. Published 2019 Oct 10.
Fisher MM, Rosen DS, Ornstein RM, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. J Adolesc Health. 2014;55(1):49-52.
Ciciulla D, Soriano VX, McWilliam V, Koplin JJ, Peters RL. Systematic Review of the Incidence and/or Prevalence of Eating Disorders in Individuals With Food Allergies. J Allergy Clin Immunol Pract. 2023;11(7):2196-2207.e13.
Farag F, Sims A, Strudwick K, et al. Avoidant/restrictive food intake disorder and autism spectrum disorder: clinical implications for assessment and management. Dev Med Child Neurol. 2022;64(2):176-182. doi:10.1111/dmcn.14977
Zickgraf HF, Murray HB, Kratz HE, Franklin ME. Characteristics of outpatients diagnosed with the selective/neophobic presentation of avoidant/restrictive food intake disorder. Int J Eat Disord. 2019;52(4):367-377. doi:10.1002/eat.23013