ARFID

ARFID is known as avoidant/restrictive food intake disorder, which is characteristed by a pattern of eating leading to avoidance and/or restriction of food.

Avoidant/restrictive food intake disorder (ARFID) is characterised by a pattern of eating where there is avoidance and/or restriction of the food type or quantity of food eaten. This tends to have negative consequences for an individual’s physical health leading to weight loss, and nutritional deficiencies.

The avoidance and/or restriction of foods in ARFID can occur for several reasons including:

• Sensory-based avoidance of food: the individual may dislike the smell, texture, taste, or look of certain foods.
• Fear of the consequences of eating: following a distressing experience with food, such as choking or vomiting, the individual may feel anxious or worried about eating.
• Lack of interest in food: some individuals with ARFID don’t feel hungry or eating may feel like a chore.

There is NO associated preoccupation with body weight or shape, or disturbance in body image.

The prevalence of ARFID is difficult to establish as it has previously been referred to by different names, including selective eating disorder.

The features of ARFID have also previously fallen under the diagnostic umbrella of ‘eating disorder not otherwise specified‘ (EDNOS) and feeding disorder of infancy or early childhood.

ARFID is often seen in younger patients compared to other eating disorders. Restrictive eating behaviours often begin in early infancy or childhood but may persist into adulthood. Although ARFID often presents in childhood and adolescence, it can also be diagnosed in adults.

The aetiology of ARFID likely to be multifactorial and include environmental and genetic factors.

Identified risk factors for ARFID include:

• Intellectual disability
• Attention-deficit hyperactivity disorder (ADHD)
• Autism spectrum disorder
• Co-occurring anxiety disorder
• “picky eating” in childhood

The diagnosis of avoidant/restrictive food intake disorder is made using the DSM-V criteria.

Avoidant/restrictive food intake disorder can be made using the DSM-V criteria.

ARFID is defined as eating or feeding disturbance (e.g. apparent lack of interest in eating or food, avoidance based on 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:

1. Significant weight loss (or failure to achieve expected weight gain).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.

The eating disturbance is NOT better explained by:

• A lack of available food
• Culturally appropriate practices

There is NO evidence of a disturbance in the way one’s body weight or shape is experienced. The eating disturbance does NOT occur exclusively in the course anorexia nervosa or bulimia nervosa.

The eating disturbance is NOT attributable to a medical condition or another mental disorder. If it occurs in the context of another disorder, the severity of the eating disturbance should exceed that routinely associated with the disorder and warrants additional clinical attention.

ARFID does not involve any distress about body shape/size or fear of fatness, which helps differentiate it from anorexia nervosa.

• Anorexia nervosa: ARFID is similar to anorexia nervosa in that both disorders involve limitations in the amount of food that is eaten and weight loss, but ARFID does not involve any distress about body shape/size or fear of fatness.
• Autism Spectrum Disorder (ASD): ASD is a common co-morbidity of ARFID, especially when restrictive eating behaviours are driven by hypersensitivity to certain sensory characteristics of food. Those with ASD also have significant difficulty with change and therefore features of ARFID may be more resistant to treatment.
• Mental health disorders causing reduced appetite and weight loss: anxiety disorders and depression may present with poor oral intake and associated weight loss.
• Medications causing reduced appetite and weight loss: for example stimulants used for the management of ADHD.
• Gastrointestinal disorders causing reduced appetite and weight loss: irritable bowel syndrome, inflammatory bowel disease, coeliac disease, and other functional disorders.
• Other medical disorders causing reduced appetite and weight loss: Type 1 diabetes mellitus, hyperthyroidism, and malignancy.

The management of ARFID will depend on the underlying cause and co-morbidities.

Currently, there are no NICE guidelines for the management of ARFID.

Management of ARFID can be split into:

• Identifying and addressing the underlying factors: psychological therapy (often cognitive-behavioural therapy) is given to address the specific factors driving the restrictive eating behaviours (e.g. sensory-based avoidance of food, fear of the consequences of eating, or lack of interest in food).
• Managing the physical health complications: ensure the patient is medically stable, correct nutritional deficiencies, and promote reaching a healthy weight. Usually, this can be done in an outpatient setting but in more severe cases, patients may require inpatient management for refeeding and optimisation of physical health.

There is a good evidence base for cognitive behavioural therapy (CBT) for the treatment of people with disordered eating behaviours. CBT focuses on the link between our thoughts, behaviours and emotions. Challenging unhelpful thoughts and behaviours can have a positive impact on how a person feels.

As with CBT to manage other eating disorders, the initial focus will likely be on gaining an understanding of the individual’s difficulties with food and eating and identifying key factors maintaining the disordered eating. It is important for the therapist to understand which foods are being avoided and why.

The therapist and patient will then work together to set goals for therapy, which will be specifically tailored to the individual. The cognitive component of CBT for ARFID might involve challenging any negative beliefs or fears about food/eating. The behavioural component of CBT for ARFID might involve establishing regular healthy eating patterns and encouraging gradual exposure to avoided foods.

For children and young people, family or carers will need to be involved in their care. It is important to provide carers with education about ARFID and explore ways in which the family might be able to support the child. Families can often help create structure and routine at mealtimes, including a calm and consistent environment, which may help reduce anxieties around eating.