What is Avoidant/Restrictive Food Intake Disorder (ARFID)?

Avoidant/Restrictive Food Intake Disorder (ARFID)

ARFID is a feeding disorder characterized by abnormal eating or feeding behaviors resulting in the intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements, leading to significant weight loss, nutritional deficiencies, dependence on nutritional supplements, or marked interference with psychosocial functioning. 1

Diagnostic Criteria

ARFID is distinct from other eating disorders like anorexia nervosa or bulimia nervosa as it does not involve body image distortion or fear of weight gain. According to the DSM-5, ARFID is characterized by:

• A feeding problem that results in at least one of the following:

  • Significant weight loss or failure to meet expected weight/height gain in children
  • Significant nutritional deficiency
  • Dependence on nutritional supplements (e.g., nasogastric feedings, oral supplements)
  • Marked interference with psychosocial functioning 1

• The problem is not attributable to:

  • Food availability or cultural practices
  • Anorexia nervosa (no body image distortion)
  • Another medical or mental condition 1

Epidemiology and Prevalence

• Prevalence can be as high as 3% in the general population 2
• Occurs across the lifespan but most research focuses on children and adolescents 3
• Often appears in children with anxiety disorders 2
• Increasingly recognized in children as young as 5 years old 1

Clinical Presentations and Subtypes

ARFID typically presents in three main patterns:

1. Sensory-based avoidance: Avoidance of foods due to their sensory characteristics (texture, smell, appearance)
2. Fear-based avoidance: Avoidance based on fear of adverse consequences of eating (choking, vomiting, pain)
3. Lack of interest in food/eating: Low appetite or limited interest in food 4

Medical Complications

ARFID can lead to serious medical complications:

• Malnutrition and significant weight loss
• Growth stunting in children
• Nutritional deficiencies
• Dependence on nutritional supplements
• Impaired psychosocial functioning 1, 2

Relationship with Other Conditions

• Significant overlap with gastrointestinal disorders and functional dyspepsia 1
• Often comorbid with anxiety disorders 2
• May overlap with disorders of gut-brain interaction (DGBI) 1
• Commonly seen in patients with hypermobility disorders/hypermobile Ehlers-Danlos Syndrome 1

Assessment

Assessment should include:

• Evaluation of nutritional status and growth parameters
• Assessment of specific food avoidance patterns
• Screening for comorbid anxiety disorders
• Ruling out other medical conditions that might explain symptoms
• Distinguishing from other eating disorders (anorexia nervosa, bulimia) 2

Treatment Approaches

Treatment should be multidisciplinary and tailored to the specific presentation:

• Psychological interventions:

  • Cognitive-behavioral therapy (CBT)
  • Behavioral interventions with food exposure
  • Family therapy
  • Anxiety management techniques 5

• Common treatment components:

  • Food exposure therapy
  • Psychoeducation
  • Anxiety management
  • Family involvement 5

• Nutritional rehabilitation:

  • Graded exposure to avoided foods
  • Nutritional counseling
  • Careful use of supplements when necessary 1, 2

Special Considerations

• Early intervention is crucial: A rapid and systematic nutrition survey should be conducted during pediatric consultations to identify ARFID early 2

• Avoid parenteral nutrition: Parenteral nutrition should be avoided in ARFID except in life-threatening malnutrition as a temporary bridge to appropriate therapies 1

• Cognitive-behavioral approach: The optimal psychological and nutritional rehabilitation approach in ARFID is graded exposure in a cognitive behavioral therapy setting rather than reinforcing restriction 1

• Multidisciplinary care: Treatment often requires a team including pediatricians, nutritional therapists, dietitians, psychologists, and speech therapists 2

Pitfalls to Avoid

• Misdiagnosis: Failing to distinguish ARFID from anorexia nervosa or other eating disorders
• Overlooking comorbidities: Missing anxiety disorders or gastrointestinal conditions that may contribute to or exacerbate ARFID
• Reinforcing avoidance: Elimination diets can increase the risk of developing or worsening ARFID 1
• Inappropriate use of supplements: Becoming dependent on nutritional supplements without addressing the underlying psychological factors 1

ARFID is a relatively new diagnostic category that requires careful assessment and a coordinated treatment approach focusing on both nutritional rehabilitation and addressing the psychological factors maintaining the feeding disorder.