What is the best approach to manage a patient with an aversion to food but preserved appetite?

Management of Food Aversion with Preserved Appetite

The primary approach depends on identifying the underlying cause: for post-bariatric patients, focus on behavioral eating modifications (slow eating, prolonged chewing ≥15 chews per bite, avoiding dry foods); for suspected avoidant/restrictive food intake disorder (ARFID), initiate cognitive-behavioral therapy or family-based therapy as first-line treatment; and for dementia patients, provide emotional support and consistent feeding assistance rather than appetite stimulants. 1, 2, 1

Differential Diagnosis and Initial Assessment

The clinical context determines the management pathway:

• Post-surgical food intolerance presents early after bariatric procedures (especially gastric banding) with difficulty consuming variety despite hunger, improving over time 1
• ARFID manifests as extreme selectivity driven by sensory sensitivities, fear of adverse consequences, or lack of interest in eating—without body image distortion—and requires comprehensive psychiatric evaluation including screening for co-occurring anxiety and autism spectrum disorders 2, 3, 4
• Dementia-related eating difficulties occur across disease stages and benefit from behavioral interventions rather than pharmacological appetite stimulation 1

Behavioral and Environmental Interventions

For Post-Bariatric Food Intolerance

Implement specific eating technique modifications to prevent food avoidance and nutritional deficiencies: 1

• Slow the pace of eating with prolonged chewing (minimum 15 chews per bite) 1
• Avoid problematic textures: doughy bread, overcooked steak, dry chicken breast 1
• Consume small quantities at each meal 1
• Progress gradually with food textures, especially after gastric band adjustments 1
• Reintroduce previously rejected foods once new eating skills are acquired 1

Common pitfall: Persistent food intolerance leads to maladaptive consumption of soft, high-calorie foods that contribute to surgical failure 1

For Dementia Patients

Provide structured feeding support rather than appetite stimulants, as systematic use of orexigenic drugs is not recommended due to limited evidence and potential harm: 1

• Ensure adequate feeding assistance at mealtimes, as lacking support correlates with low food intake 1
• Maintain consistent caregivers during feeding, which increases food consumption in severe dementia 1
• Implement behavioral and communication strategies with emotional support 1
• Place patients at dining tables with supervision, verbal prompting, and encouragement 1

Evidence note: While dronabinol showed weight gain in one small 12-patient RCT, and megestrol acetate had inconsistent results in nursing home residents, the systematic use of appetite stimulants cannot be recommended due to unknown mechanisms of action and potentially harmful side effects 1

Psychotherapy for ARFID

Eating disorder-focused cognitive-behavioral therapy (CBT) is the first-line psychotherapy, available in individual or group formats: 2

• Interpersonal therapy (IPT) serves as an effective alternative 2
• Family-based therapy is particularly relevant for pediatric presentations 2, 3
• Treatment should address sensory processing disorders when present 5

Clinical context: ARFID remains underrecognized, with <20% diagnosed before hospitalization despite 60.5% having seen primary care providers for feeding concerns 4

Pharmacotherapy Considerations

For Binge Eating Component (if present)

• Lisdexamfetamine (Vyvanse) is FDA-approved for moderate to severe binge eating disorder 2
• SSRIs may be considered as alternative pharmacological options 2

For ARFID

• Pharmacotherapy is used adjunctively with psychotherapy, particularly when psychiatric comorbidities exist 2, 3
• 63.2% of hospitalized ARFID patients required psychiatric medications during admission 4

Not Recommended

Appetite stimulants (dronabinol, megestrol acetate) are not systematically recommended due to very low quality evidence, inconsistent effects, and potential adverse effects: 1

Red Flags Requiring Escalation

Monitor for complications necessitating medical intervention: 1, 4

• Persistent vomiting >2-3 weeks requires thiamin supplementation to prevent neurological complications 1
• Refractory symptoms despite behavioral compliance may indicate surgical complications (stricture, obstruction, band slippage) 1
• Nearly one-quarter of ARFID patients require medical admission, with average length of stay 8 days 4
• Almost half of hospitalized ARFID patients require enteral tube feeds 4

Monitoring and Follow-up

Establish coordinated multidisciplinary care incorporating medical, psychiatric, psychological, and nutritional expertise: 2

• Regular assessment of eating behaviors and nutritional status 2
• Weight monitoring without making weight loss the primary treatment focus 2
• Maintain adequate hydration (1.5 L liquids daily), as dehydration accounts for one-third of post-bariatric emergency visits 1

Documentation pitfall: Only 31.6% of hospitalized ARFID patients had the diagnosis documented in discharge notes, contributing to care fragmentation 4