October 2015 Issue

Eating Disorders: Avoidant/Restrictive Food Intake Disorder
By Kaley Todd, MS, RDN
Today's Dietitian
Vol. 17 No. 10 P. 70

This recently specified condition may be the culprit behind picky eating.

Many children are fussy eaters and avoid certain foods because of taste or texture preferences. While in many cases this appears to be a normal part of growing up, avoiding foods can be a sign of a more serious condition. Emma, aged 4, was an extremely picky eater. She ate fewer than five different foods daily and only items that were white in color. Potatoes, white bread, and chicken nuggets were staples. She'd throw tantrums at the sight of other foods on her plate. Her picky eating began with occasional refusals to eat certain items, but it worsened. And as a result, she wasn't growing as expected. After seeing her pediatrician, Emma not only was classified as malnourished, but also was diagnosed with a newly defined eating disorder—avoidant/restrictive food intake disorder (ARFID).1

An Overview
ARFID expanded the criteria for eating disorders and replaced the seldom-used feeding disorder of infancy or early childhood diagnosis, as described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).2 ARFID is a broad category that includes individuals of all ages who substantially restrict their food intake and experience significant associated physiological or psychological problems. The diagnosis comprises individuals presenting with clinically significant restrictive eating problems, including those who meet existing criteria for the DSM-IV category, such as impaired development of feeding or eating skills, difficulty with digesting or with intake of fluids or foods, refusal to eat due to a dislike of certain sensory characteristics of foods; and a more general lack of appetite or interest in eating.3 The ARFID diagnosis also captures individuals who present with clinically significant eating problems not included in the defined DSM-IV categories, and that were previously assigned a diagnosis of eating disorder not otherwise specified, which is characterized by the following:

• inadequate food intake based on a restricted range of foods eaten or a restricted caloric intake that doesn't lead to weight loss or significant growth impairment;

• reduced food intake due to an emotional disturbance related to eating, without concern for body shape/size or weight; and

• hesitation regarding food intake following an eating-related adverse event. For example, a person may restrict food intake due to a fear of swallowing after a frightening episode of gagging, choking, or vomiting.4

Because ARFID is a newly defined eating disorder, limited research has been published. However, a 2014 retrospective chart review, comparing a cohort of children and adolescents undergoing day treatment for eating disorders, reported the following findings:

• Almost one-quarter of patients were diagnosed with ARFID, illustrating the significant prevalence of this disorder among children and adolescents.

• The majority of diagnosed cases were female, but a higher percentage than expected were male.

• Children and adolescents with ARFID were more likely to show significant weight loss or inadequate weight gain.

• Patients with ARFID tended to have higher dependency on oral or enteral nutrition supplementation.

• Subjects expressed significantly more fears of choking and vomiting, as well as texture and sensitivity issues regarding food.5

Sondra Kronberg, MS, RD, CDN, CEDRD, director of the Eating Disorder Treatment Collaborative/Family and Friends Eating Events and Direction and spokesperson for the National Eating Disorders Association, says ARFID is different from other eating disorders such as anorexia nervosa and bulimia nervosa. "ARFID is unique because it doesn't usually stem from concerns of body image," Kronberg says. "Individuals diagnosed with ARFID typically avoid foods because of somatic senses like taste, texture, or smell." According to an article published in the May/June 2013 issue of Eating Disorders Review, risk factors for ARFID may include the presence of gastrointestinal conditions and psychological disorders, including anxiety, autism spectrum, obsessive-compulsive, and attention deficit disorders.4

Treatment and Counseling Tips
Currently, little is known about effective treatment options for individuals with ARFID; however, successes have been reported when similar methods used to treat other eating disorders were employed. Because children and adolescents experience weight loss and low mean body weight percentages as do those who have anorexia nervosa, they're at risk of developing the same medical complications.6 Dana Magee, RD, LD, CLT, a dietitian in Columbia, Maryland, who treats children with eating disorders, says the first step in treatment is to ensure that the patient is medically stable. "Often patients with ARFID are malnourished and have experienced poor weight loss and growth. Determining the extent of nutrition imbalance and addressing any immediate needs is essential," Magee says.

Health care professionals agree that individualized treatment is most effective and should include a multidisciplinary health care team approach. Chrissy Barth, MS, RDN, RYT, a dietitian and yoga instructor in Phoenix, says "it's best to treat children with ARFID in a multidisciplinary arena, including a psychologist and dietitian who specialize in eating disorders." Communication and trust are essential throughout the treatment process, as well as educating the child and family about nutrition and discussing the child's fears about food, she says.

Determining the degree to which ARFID interferes with the patient's quality of life and assessing the emotional, physiological, and behavioral components are essential for choosing the best treatment. "Evaluating these elements on an individual basis is key in finding the best route of treatment," Kronberg says. Practitioners have found behavior therapies such as exposure therapy, a technique used to overcome anxiety by exposing the patient to the feared object or context without any danger, to be effective. "Exposure treatment coupled with behavior modification and self-comfort techniques have been beneficial in treating individuals with ARFID," Kronberg says. "The goal is to broaden the scope of foods they're comfortable with, and help them to change their patterns so eating becomes enjoyable."

ARFID often is treated through anxiety management and systematic desensitization, gradually rewarding the introduction of new foods. Relaxation techniques are used to minimize stress. A safe environment should be created where feared foods are slowly integrated into the eating plan. Consuming a meal together with meal processing, visualization, art therapy, and psychotherapy also can be useful in treatment. Barth has found that mind/body therapies such as yoga are useful during recovery. "Yoga therapy is beneficial for establishing the mind-body connection in a nurturing way, learning how to be kind and to take care of oneself, and helps relieve depression and anxiety," Barth says.

Children and adolescents with ARFID are distinct from those who suffer from other eating disorders, and now they can be identified more specifically and accurately, leading to speedier access to care. The degree of physical and psychosocial dysfunction with which these patients present indicates the need for prompt and appropriate treatment. Further research on ARFID will help practitioners understand this diagnosis and determine the best treatment methods for those plagued with the disorder.

— Kaley Todd, MS, RDN, is a San Francisco-based freelance writer, clinician, and culinary and communications specialist. She's the founder of Kaley Todd Nutrition at www.kaleytoddnutrition.com.

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

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Publishing; 2000.

3. Bryant-Waugh R, Markham L, Kreipe RE, Walsh BT. Feeding and eating disorders in childhood. Int J Eat Disord. 2010;43(2):98-111.

4. Kenney L, Walsh BT. Avoidant/restrictive food intake disorder (ARFID) — defining ARFID. Eat Disorders Rev. 2013;24(3):1-4.

5. Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord. 2014;2(1):21.

6. 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.

• Academy for Eating Disorders: www.aedweb.org
• International Association of Eating Disorder Professionals: www.iaedp.com
• National Eating Disorders Association: www.nationaleatingdisorders.org

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition defines the following diagnostic criteria for ARFID:

Disturbance in eating or feeding, as evidenced by one or more of the following:

• substantial weight loss, or absence of expected weight gain in children;

• nutritional deficiency;

• dependence on a feeding tube or dietary supplements;

• significant psychosocial interference;

• disturbance not due to unavailability of food or to observation of cultural norms;

• disturbance not due to anorexia nervosa or bulimia nervosa, and no evidence of disturbance in experience of body shape or weight; and

• disturbance not better explained by another medical condition or mental disorder; or when occurring concurrently with another condition, the disturbance exceeds what's normally caused by that condition.

— KT