Understanding Avoidant/Restrictive Food Intake Disorder (ARFID) - overview

Dr. Megha

MBBS | Freelance Medical Writer

12 Jul 202410 min read

girl having avoidant/restrictive food intake disorder.

It was around 1:30 p.m. when Maya and her friend sat down to have lunch.

“Hey, my mom's in town, and she has prepared her phenomenal green pea masala. You have to try it!’’, said Mehak, one of Maya’s friends.

Maya felt a lump in her throat. All the flashbacks started kicking in. “Umm…no, Mehak. I think I'll pass.”

“Huh? Why? Just try a bit. I'm sure you'll like it.”

Maya remained silent.

“Alright, what's the big deal, Maya? Am I missing something here?”

“Ahh… I guess it's safe to tell you now. When I was 6 years old, my mom prepared the same green pea masala. I didn't like how it looked, and I found the smell pungent for some reason. So I said I didn't want it. After a couple of failed attempts, mom tried to force-feed me, and I ended up choking. I had to be rushed to the hospital that day. Since then, I've never eaten green peas or anything that looks similar. It makes me very uncomfortable. I have tried to change it, but the trauma just seems to get stronger. I am sorry, Mehak, if I hurt you.”

Mehak felt sorry for Maya, consoled her, and apologized for trying to get her to eat it.

“Maya, can I ask you something, though? Have you tried talking about this with a healthcare professional? I mean, I have seen how reluctant you are in general to have certain foods, but I didn't know the reason behind it.”

“Yeah Mehak. I have. This is not just it; I have been like this around food for a long time. It's like I don't have enough appetite most of the time. And 3 months back I got diagnosed with ARFID.”

“Oh, mind telling me what's that?”

What is ARFID?

Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder in which an individual consumes significantly fewer amounts of food or avoids specific food items, often resulting in malnutrition and weight loss.

The reason why people with ARFID limit or undereat food is due to sensory characteristics of food such as colour, appearance, and texture; negative experiences such as choking or vomiting with food, as described in the above scenario, where the person had a negative psychological association with a particular food item; or it can be a combination of all these factors.

ARFID can affect all genders and age groups. It is often associated with other medical conditions such as depression, OCD, ADHD..

Prevalence of Avoidant Restrictive Food Intake Disorder

The prevalence of ARFID in the general population is within the following range: 0.35-3.2% in children, 1.98% in adolescents, and 0.3-3.1% in adults.

In the USA, a study showed that 0.5-5% of children and adults in the general population are diagnosed with ARFID. However, research on ARFID is ongoing, as we need more specific data regarding the prevalence of ARFID.

Distinguishing Avoidant Restrictive Food Intake Disorder from Picky Eating

ARFID can sometimes be confused with picky eating due to certain similarities. In fact, some experts do refer to ARFID as “extreme picky eating," but it is imperative to understand the difference.

Picky eating is commonly seen in children, where they might avoid certain foods because of their peculiar taste and smell, but it's a phase that goes away with age. ARFID, on the other hand, doesn't go away without treatment and may worsen over time.

People with ARFID may find it difficult to eat in social situations, take longer to finish their meals, tend to lose weight, and have severe health problems in the long run.

Causes of Avoidant Restrictive Food Intake Disorder

The exact causative factors of ARFID are unknown. Several studies and research suggest the following may play a role:

Fear and anxiety around food:

Previous bad experiences with food, such as choking or vomiting, may have an influence on the development of ARFID.

Genetic or biological factors:

Genes have a huge influence on ARFID, like any other eating disorder. Healthcare professionals haven't been able to find out the exact genes linked to ARFID. But, research has found that genetics can contribute to almost 80% of an individual's chance of developing ARFID.

Traumatic experiences:

In some individuals, trauma can lead to the onset of ARFID. Traumas such as unstable family dynamics, divorce or migration may contribute to the development of ARFID in children.

Social, cultural and Environmental factors:

Cultural pressure on an individual to eat the ‘right’ way and certain beliefs around food are also responsible. Other cultural or environmental factors include influence from family members, such as meal preparation methods, exposure to a particular food and diet, or highly restricted eating practices at home.

This can make the individual sensitive to a particular food's texture and smell and eventually lead to ARFID.

Signs & Symptoms of Avoidant Restrictive Food Intake Disorder

Following are the common signs and symptoms of ARFID:

Severe weight loss
Abdominal pain and cramps
Constipation
Lethargy
Muscle weakness
Low body temperature or feeling cold often
Irregular menstrual cycles
Dry skin and nails
Hair thinning
Fine, thin body hair (lanugo)

In addition, certain psychological and behavioural symptoms are also seen in people with ARFID, such as :

Lack of interest to try new foods
Avoiding specific foods due to texture and consistency
Having little to no appetite (feels full before a meal)
Difficult to eat with others around
Heavy restriction in the amount and kind of foods to eat
Trouble concentrating
Fear and anxiety about choking and vomiting
Dresses in several layers to keep oneself warm

Risk Factors and Complications of Avoidant Restrictive Food Intake Disorder

Remember that anyone can have ARFID, be it a child or an adult. Sometimes ARFID may develop in childhood and later carry over to adulthood. These are a few possible risk factors:

Family history of ARFID or other eating disorders
Co-existing or underlying conditions such as ADHD, autism, anxiety or depression
Traumatic experiences involving food, such as force-feeding, food poisoning, choking, or vomiting
Constant fear that food will cause harm to one's body
Aversion to certain textures, appearances, and smells.

As mentioned above, ARFID doesn't just go away without necessary intervention.

Untreated ARFID may lead to the following complications:

Severe nutritional deficiencies and malnutrition
Low blood pressure
Dehydration
Electrolyte imbalance
Anaemia
Low bone density and osteoporosis
Cardiac complications
Kidney and liver failure
Stunted growth in children
Late puberty in adolescents
Overall decrease in the rate of physical growth

What are the 5 types of Avoidant Restrictive Food Intake Disorder

ARFID, previously known as “selective eating disorder,” was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.

Depending on the symptoms experienced by the individual, there are 5 types of ARFID. They are:

1.Avoidant ARFID

This is the most common type of ARFID. In this, individuals avoid certain foods because of their sensory characteristics — texture, colour, and appearance. For example, if someone hates food with rough and flaky textures, they might avoid it to such an extent that it takes a toll on their nutritional balance.

2.Aversive ARFID

This type is usually associated with a fear of food and the havoc it may cause. The fear is mostly irrational, as it doesn't pose a real risk. Usually, the thought of fear revolves around nausea, choking, vomiting, and pain while swallowing, which severely restricts the individual from avoiding food as a whole.

3.Restrictive ARFID

People with this condition simply don't have an interest in eating. They might forget to eat at all and have very little appetite. Eating feels like a “chore” to them. It is very difficult for them to sit through an entire meal, as they're extremely distracted. Also, they're immensely picky and consume a very narrow range of food items, thereby leading to limited food intake.

4.Adult ARFID

ARFID in adults is as common as it is in children. In most cases, it can be a continuation of childhood ARFID and over time, can become even more difficult to cope with.

Additionally, adults may also face challenges when it comes to social eating due to the stigma associated with this condition. Adults with ARFID can also become extremely selective or picky eaters and can have mixed features of avoidant, aversive, and restrictive ARFID.

5.ARFID plus

This is seen in individuals who have more than one type of ARFID and may develop symptoms similar to those of anorexia, such as concerns and negative images regarding body image and weight. The mix of conditions can make treatment more complex and requires a more sophisticated approach to address the underlying conditions.

Diagnosing Avoidant Restrictive Food Intake Disorder

Many components are involved in the diagnosis of ARFID.

To get an understanding of the behavioural and eating patterns, your doctor may ask you a set of relevant questions, such as the amount of food intake, frequency of meals, aversions, if any, and why. They may do a physical examination to analyse body weight, height, and general health status. This may be followed by a series of blood and urine tests to check for any nutritional deficiencies, monitor the overall working of your vital organs, and rule out any other medical conditions.

Outline of Criteria for diagnosis of Avoidant Restrictive Food Intake Disorder

A doctor looks for the following features that fall under DSM criteria to diagnose ARFID:

Notable nutritional deficiencies due to inadequate food intake
Failure of weight gain in kids and significant weight loss in adults
Dependence on oral supplements to maintain good health
Having to rely on tube feeding
Limited food intake cannot be attributed to its availability
Absence of negative or distorted associations with body image
Deterioration in psychosocial capacity
Restricted feeding is not associated with any other mental or physical illness.

Who treats Avoidant Restrictive Food Intake Disorder?

The medical team to provide the necessary measures and support for ARFID may include:

A psychiatrist/ primary physician
A psychologist or mental health care professional focusing on cognitive behavioral therapy (CBT)
A certified dietician
Speech-language pathologist/ speech therapist (if the concern around fear of food is choking)
Gastroenterologist

Effects of Avoidant Restrictive Food Intake Disorder

The impact of ARFID can give rise to significant short term as well as long term effects such as :

Short-term effects

Stomach cramps
Constipation
Fainting or dizziness
Sleep disturbances
Delayed or poor wound healing
Brittle hair, skin and nails

Long-term effects

Low immunity
Stunted growth and delayed development
Low counts of blood cells, electrolytes
Malnutrition
Dental issues
Permanent dependence on tube feeding
Damage to vital organs

Associated Mental Health Disorders

As mentioned in the beginning, ARFID can often be seen in association with other mental health conditions as well. To name a few:

ADHD
Autism
Anxiety disorders
Obsessive-Compulsive Disorder (OCD)
Depression

Treatment of Avoidant Restrictive Food Intake Disorder

ARFID is a complex disorder affecting both mental and physical health and requires a multidisciplinary approach. Each person with ARFID requires a plan tailored to their symptoms and concerns to provide necessary care and support in:

attaining optimum weight
managing associated nutritional deficiencies
developing a healthier connection with food

Therapies for Avoidant Restrictive Food Intake Disorder

The main aim of therapy is to help patients with ARFID reduce engaging in disordered eating behaviours.

1.Cognitive Behavioral Therapy (CBT)

In patients with ARFID, CBT helps to achieve a sense of control and understand the need for food consumption. It also helps to decrease the negative associations and triggers associated with food.

2. Dialectical Behavioral Therapy (DBT)

DBT aims to impart mindfulness and deal with emotional distress effectively. This may help in reducing restricted food intake and its avoidance.

3. Speech therapy

Speech therapy can help people with ARFID who face challenges with chewing and swallowing food. Speech therapy helps to improve the action of the oral-motor muscles.

Medications for Avoidant Restrictive Food Intake Disorder

There is no single medication solely for ARFID. But what doctors may do is prescribe supplements to treat nutritional deficiencies and medicines to stimulate appetite. Some may prescribe medicines to treat co-existing conditions, such as anxiety or depression.

Treatment of ARFID patients

ARFID in children can be mostly treated at home, but those with severe malnutrition or life-threatening conditions will need hospitalization. Additionally, some children with ARFID might need tube feeding to receive enough nutrition.

Adult ARFID treatment mainly involves the above mentioned methods, with CBT being the most effective of all.

Responsive feeding therapy (RFT) is a method that is beneficial in the treatment of ARFID in children and adults. It involves establishing mealtime routines in a comfortable environment with pleasant conversations.

In a review article focusing on the treatment outcomes of people with ARFID, it was observed that there was significant improvement in disordered eating patterns, and people who were underweight (low BMI) at the beginning of the treatment had successfully gained weight.

How to help someone with Avoidant Restrictive Food Intake Disorder?

If a loved one is trying to recover from ARFID, here are a few tips that may help:

Offer validation. As part of their treatment, they may be subjected to food exposures, which can be overwhelming. It is vital to be there and offer compassion and support.
Lend a non-judgemental ear to them. Many children and adults with ARFID suffer in silence due to the fear of judgement from people around them. Creating a safe space for them to vent is crucial.
Be patient. Getting angry with them or forcing them to eat isn't going to help. On the other hand, it may put them in more emotional distress and worsen the condition.
Educate yourself and understand more about the impacts of ARFID and other eating disorders on one's health. Simply be there for them.

FAQ

What's the Difference: between ARFID vs. Anorexia?

A person with ARFID restricts or avoids food, but unlike anorexia, it is not due to body image distortion but rather due to sensory characteristics and a fear of risk around food.

In anorexia, the patient has negative body image and is motivated to lose weight, leading to severe food restrictions.

Can ARFID turn into anorexia?

Yes, but it is rare. It is possible for some people who have extreme sensitivities and disgust toward food and develop a generalised disgust toward one’s body, especially in transitional phases such as puberty.

Conclusion

ARFID is a complex mental condition that has significant physical effects. Sensitivity to food based on colour, texture, and smell; trauma, or witnessing unpleasant scenarios can contribute to its development. Unlike picky eating, ARFID doesn't resolve on its own and requires medical attention. It is important to seek help, as in today's world, where there's an advancement almost every day in the field of medicine and research, the modes of treatment are promising.

Like other eating disorders, one has to remember that people living with ARFID also deserve the utmost love, care, and support from their loved ones.