May 2019 Issue

Healthy Gut: Assessing for ARFID in Patients With IBS
By Kate Scarlata, RDN, and Megan Riehl, PsyD
Today’s Dietitian
Vol. 21, No. 5, P. 10

Patients with irritable bowel syndrome (IBS) commonly develop food-related fears, as they’re often plagued by the onset of abdominal pain, cramping, bloating, diarrhea, or constipation whenever they eat or drink certain foods and beverages containing carbohydrates. But when these food fears greatly impact their ability to meet nutrition needs or exacerbate significant anxiety, greater clinical attention is warranted, as this may be a sign of avoidant/restrictive food intake disorder, otherwise known as ARFID.

ARFID was introduced in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition as a diagnosis of eating or feeding disturbance due to lack of interest in eating, avoidance of sensory characteristics of food, and/or fear of adverse eating consequences (eg, choking, vomiting, or digestive distress).1 To meet diagnostic criteria, one doesn’t have a distorted body image and the food disturbance must lead to one or more of the following: nutritional deficiency, weight loss, psychosocial impairment, or dependence on oral nutritional supplements or tube feedings. ARFID can’t be diagnosed if the eating disturbance is attributable to a concurrent medical or psychiatric condition.

While feeding disorders commonly have been disorders of childhood, ARFID has a more diverse clinical presentation, affecting a wider range of demographics and comorbidities. Very little research has examined the assessment, treatment, and impact of ARFID in adults. And it’s hypothesized that ARFID is an underrecognized disorder in adults with gastrointestinal (GI) disorders such as IBS, but the exact impact is unknown.

Clinical Scenario: ARFID + IBS
In clinical practice, an individual with IBS may present with GI distress, have self-imposed significant food limitations resulting in inadequate nutrition, and mention that food makes their symptoms worse. A trip to the gastroenterologist ends with the recommendation of a dietary intervention, such as a low-FODMAP diet. Further diet restriction results in prolonged avoidant behaviors, increased anxiety, worsened psychological health, and increased reductions in nutritional intake.

For improved management of maladaptive eating, a multidisciplinary treatment team that may include a gastroenterologist, dietitian, and GI psychologist can screen for the presence of maladaptive eating common to ARFID. A provider can discuss the ARFID diagnosis and instill hope that treatment is available. When the individual receives appropriate care, overall health can dramatically improve.

Researchers haven’t identified the long-term consequences of patients with ARFID undergoing the low-FODMAP diet, but they’ve begun to recognize that screening for ARFID in the GI patient population is important and acknowledge the potential for psychiatric comorbidity. Preliminary research by Zia and colleagues found that approximately 21% of their functional GI disorder patient sample met criteria for ARFID.2 However, these early data must be interpreted with caution; we don’t want to be too quick to assign an eating disorder to GI patients given the individuality of one’s sensitive gut to potential food triggers and associated behaviors. Skilled dietitians and mental health specialists with expertise in gastroenterology are critical in the assessment and treatment of these patients.

Multidisciplinary Approach for IBS Care
A recent meta-analysis showed that levels of depression and anxiety are much higher in patients with IBS compared with healthy controls, regardless of IBS subtype.3 Patients may experience psychiatric comorbidity before the onset of IBS, but they also may develop GI-specific mood symptoms driven by the disorder’s complexities. Psychological interventions targeting the brain-gut axis and mood symptoms have been found to reduce the severity of IBS symptoms.4

Often, behavioral interventions for these patients are aimed at addressing the anxiety associated with the uncontrollable aspects of their symptoms. The desire to be in control of symptoms can drive unhealthful, avoidant behaviors that can include overly restrictive diets and/or activities. In addition, eating disorders can be masked by GI symptoms, with up to 98% of eating disorder patients meeting criteria for at least one functional GI disorder in one study.5

Food is a commonly self-perceived trigger of IBS symptoms. One study noted that up to 84% of individuals with IBS believed food caused the symptoms, with carbohydrates noted as the most likely trigger.6 If food has been identified as the culprit of unbearable cramping and bowel disturbance, it follows suit that individuals would adjust their diet to control symptoms.

Therefore, awareness of ARFID criteria when working with GI patients is important in terms of ensuring the treatment plan doesn’t further exacerbate the patient’s current avoidance of specific food groups.

Nutritional Intervention for IBS
Given the heterogeneity of IBS, including clinical history and severity, it’s important for dietitians to provide personalized nutrition plans for patients. There has been great interest in the low-FODMAP diet for IBS symptom management, as it’s the first IBS diet intervention that has science to support its use in this patient population, managing GI symptoms in 50% to 70% of IBS sufferers.7,8 In many individuals who felt food exacerbated their symptoms, a low-FODMAP diet validated this connection. Interestingly, the low-FODMAP diet has been shown to increase IBS-related quality of life scores and reduce levels of anxiety.9 The low-FODMAP diet can be a therapeutic intervention in many with IBS, but care should be used when selecting the appropriate patient for this approach. The low-FODMAP diet is intended for short-term use, and the challenge phase can become emotionally difficult for some patients. It isn’t indicated when an eating disorder is present.

As health care providers, dietitians need to take the “do no harm” approach to treatment when working with patients with IBS, particularly those who may be more at risk of an eating disorder. Practitioners can’t use anthropometric data to assess a patient’s risk for maladaptive eating or an eating disorder. In outpatient behavioral health treatment, it has been observed that GI patients with a BMI in the normal range met criteria for ARFID, again highlighting the complexity of this diagnosis and the need for careful evaluation.

Screening and Intervention for ARFID
Although eating patterns such as the low-FODMAP diet can help minimize IBS symptoms, screening for ARFID first is a good idea to better select individualized treatments and avoid worsening maladaptive eating.

To screen patients, ask whether they have a history of disordered eating and how they feel about their current body image, and routinely use an eating disorder screening measure such as the Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS), SCOFF, or Eating Attitudes Test (EAT-26).10-12 It should be noted that these screening tools haven’t been validated in the IBS population, but they provide some guidance until a proven tool is available for these patients.

Providing eating disorder screening questions as part of a patient previsit digestive health summary form can be a useful tool for dietitians to begin assessing whether maladaptive eating or an eating disorder is present. The NIAS, SCOFF, and EAT-26 questionnaires provide key questions that can be incorporated into a self-designed dietetics assessment. Evaluating 24-hour dietary recalls and food frequency questionnaires also can offer insights into a patient’s eating pattern.

RDs should look for red flags such as limited range of foods, lack of food groups, or insufficient nutrient intake to help determine the best nutritional approach for patients. If dietitians suspect ARFID or another eating disorder after reviewing the patient’s eating pattern, they should refer the individual to an eating disorder specialist. Working with patients to slowly add back foods to increase nutrition can be the first step to help them start trusting their body and food again. Dietitians may find that adding back low-FODMAP foods to a patient’s limited diet will offer successful reintroductions given the known link between fermentable carbohydrates and IBS symptom exacerbation. Rather than educate patients on the low-FODMAP diet, dietitians can simply structure food selection within the low-FODMAP framework. Successful reintroductions of foods can be both mentally and physically supportive for patients.

If an IBS patient is diagnosed with ARFID, referring him or her to a GI psychologist for cognitive behavioral therapy is currently the only treatment approach that’s been affirmed in the literature. Given the diversity of ARFID, different patients will require different interventions and levels of care. While current ARFID research is limited, several groups are beginning to evaluate the use of cognitive behavioral therapy.13 Treatment may require the expertise of a skilled mental health professional to aid in establishing patterns of routine eating with normalization of hunger cues, increasing volume and variety of foods, addressing sensory sensitivities and fears of adverse consequences, and possibly addressing the lack of appetite or interest in food through interoceptive exposure to symptoms of fullness, bloating, or nausea.

Bottom Line
Nutrition therapy for patients with IBS should first involve a screening tool for eating disorders. If ARFID is suspected, refer patients to a mental health professional with expertise in this condition. It’s important to remember that not all IBS patients have an eating disorder and that food is a common self-perceived trigger in IBS, so personalizing nutrition interventions in this population is key. Finally, the low-FODMAP diet can be a great tool to help many IBS patients manage symptoms, but it isn’t indicated when an eating disorder or extreme food fears are present.

— Kate Scarlata, RDN, is a Boston-based dietitian with an expertise in gastrointestinal disorders and food intolerance.

— Megan Riehl, PsyD, is a gastrointestinal health psychologist and clinical director of the gastrointestinal behavioral health program at the University of Michigan in Ann Arbor.


1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric Publishing; 2013.

2. Zia JK, Riddle M, DeCou CR, McCann BS, Heitkemper M. Prevalence of eating disorders, especially DSM-5’s avoidant restrictive food intake disorder, in patients with functional gastrointestinal disorders: a cross-sectional online survey. Gastroenterology. 2017;152(5 Suppl 1):S715-S716.

3. Lee C, Doo E, Choi JM, et al. The increased level of depression and anxiety in irritable bowel syndrome patients compared with healthy controls: systematic review and meta-analysis. J Neurogastroenterol Motil. 2017;23(3):349-362.

4. Riehl ME. The emerging role of brain-gut therapies for irritable bowel syndrome. Gastroenterol Hepatol (N Y). 2018;14(7):436-438.

5. Boyd C, Abraham S, Kellow J. Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders. Scand J Gastroenterol. 2005;40(8):929-935.

6. Böhn L, Störsrud S, Törnblom H, Bengtsson U, Simrén M. Self-reported food-related gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life. Am J Gastroenterol. 2013;108(5):634-641.

7. Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A randomized controlled trial comparing the low FODMAP diet vs. modified NICE guidelines in US adults with IBS-D. Am J Gastroenterol. 2016;111(12):1824-1832.

8. Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014;146(1):67-75.e5.

9. Eswaran S, Chey WD, Jackson K, Pillai S, Chey SW, Han-Markey T. A diet low in fermentable oligo-, di-, and monosaccharides and polyols improves quality of life and reduces activity impairment in patients with irritable bowel syndrome and diarrhea. Clin Gastroenterol Hepatol. 2017;15(12):1890-1899.e3.

10. Zickgraf HF, Ellis JM. Initial validation of the Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS): a measure of three restrictive eating patterns. Appetite. 2018;123:32-42.

11. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999;319(7223):1467-1468.

12. Eating Attitudes Test — 26 Item. Psychology Tools website.

13. Thomas JJ, Wons OB, Eddy KT. Cognitive-behavioral treatment of avoidant/restrictive food intake disorder. Curr Opin Psychiatry. 2018;31(6):425-430.