What Is ARFID? Avoidant Restrictive Food Intake Disorder Explained
Picky eating is common among kids (and even adults), with most people eventually growing out of it. But when this doesn't happen — and you go as far as to refuse to eat an entire food group to the point that your health is at stake — Avoidant Restrictive Food Intake Disorder (ARFID) may be at play.
According to a paper published in Current Problems in Pediatric and Adolescent Health Care, ARFID, formerly known as Selective Eating Disorder, became a new diagnosis in May 2013 when the American Psychiatric Association (APA) released its 5th edition of the "Diagnostic and Statistical Manual" (DSM-5). The updated publication expanded on what was once known as Feeding Disorder of Infancy or Early Childhood. Per the National Eating Disorders Association, while characterized by limiting the food one eats, ARFID involves a potential lack of interest in food, refusal to eat foods with certain textures, and fear of what might happen from eating the food.
ARFID can even affect social and familial relationships. "We knew that we had a problem when our family was unable to go out to dinner or attend social events without having to worry if there would be food our daughter could eat," mom Stephanie Elliot wrote in a blog post for the National Eating Disorders Association.
With ARFID being such a relatively recent diagnosis, it's especially important to understand the facts about it.
ARFID is a misunderstood condition
As a recently defined condition, ARFID seems to be challenging to identify for both the medical community and the public.
Daniel Le Grange, PhD, director of the University of California, San Francisco's Eating Disorders Program, shared the facts with the Child Mind Institute. "What distinguishes ARFID from [other eating disorders] is their worry about the taste, texture, color or even 'movement' (such as Jell-O) of food," he said. This results in avoiding many foods, sometimes even entire groups of foods. Parents become frustrated because they don't understand their children's motivations. Those with ARFID may be underweight, but this is not always the case, Le Grange noted. In addition, the disorder appears at much younger ages than eating disorders such as anorexia and bulimia. And because it can be difficult to distinguish between ARFID and typical picky eating, diagnosis is often delayed.
This describes the experience of Anne Bouchard, who has a son with ARFID, as she detailed in a blog post for the National Eating Disorders Association. "Aversion to trying new foods was something we noticed in our boy as early as the feeding years," she wrote. "We'd share our experiences and concerns with family, friends, and medical experts, though our explanations and observations were often dismissed. Most reassured us the 'picky eating' was just a phase. We felt dismissed and alone in our quest for answers ... It was clear to us that something was not being acknowledged."
ARFID shares both similarities and differences with anorexia
As noted, those with ARFID may or may not appear underweight and are not purposely trying to lose weight. "Kids with ARFID don't particularly care about weight or shape, definitely not in the way that young people with bulimia nervosa, typical anorexia nervosa or atypical anorexia nervosa do," as Daniel Le Grange, PhD, who leads the Eating Disorders Program at the University of California, San Francisco, shared with the Child Mind Institute.
As noted in an article from Current Problems in Pediatric and Adolescent Health Care, those with ARFID may want to eat more and gain weight; they just struggle to do it. While the motivations and desires of those with ARFID differ from those with eating disorders such as anorexia and bulimia, a study published to the Journal of Eating Disorders found that the amount of psychological distress on individuals with both disorders is similar.
"People with ARFID suffer from depression and anxiety as a result from the fear, and then the inability to find a way to relieve the symptoms. When it presents in children, it's easy to become depressed and the anxiety becomes so high that they alienate, and they tend to withdraw from social events," Stephanie Elliot, mom to a daughter diagnosed with ARFID, wrote in a blog post for the National Eating Disorders Association. She added that kids end up emotionally shutting down when their parents try to persuade them to eat.
ARFID shows up in patients in a number of ways
ARFID is associated with a variety of signs and symptoms affecting both mental and physical health. According to the National Eating Disorders Association, psychological and behavioral signs may include a weak appetite, restrictions in the amount and type of food eaten, fears of choking or vomiting, and difficulty concentrating. Those with ARFID may also have a history of picky eating that might get worse over time. They may dress in layers or wear loose clothing to hide weight loss or to keep warm.
The physical symptoms and signs include unexplained gastrointestinal problems during meals, constipation, stomach pain, tiredness, intolerance to cold, swollen feet, thinning hair, irregular menstrual cycle, muscle weakness, sleep difficulties, dry skin, dizziness, and fine hair growth. Those with ARFID might also have wounds that are slow to heal as well as a history of fainting. Per ADDitude magazine, those with ARFID are likely to be slow eaters, taking at least 45 minutes to eat.
One woman named Kelsey shared her story with Medical News Today, explaining that her symptoms resulted from watching her younger brother's eating difficulties. She began experiencing constant nausea and gastrointestinal symptoms. "The more I struggled with these things the more I didn't have any answers."
ARFID can be categorized by three main types or motivations
ARFID is distinguished by three distinct types or motivations: lack of interest in food or eating, sensitivity to certain textures (or even particular colors, smells, and tastes, per Child Mind Institutes) of food, and fear of choking or throwing up or functional dysphagia (via a paper in Current Problems in Pediatric and Adolescent Health Care). This can be a result of observing others' similar behavior, having experienced a traumatic incident involving food, or for no apparent reason (per Current Psychiatry Reports).
A woman named Heather described her experience with ARFID to Medical News Today. In Heather's case, her difficulties stemmed from food textures, which led to her being branded as the family's picky eater. "Sitting at the dinner table as a kid ... I'd sit there for hours facing the fear of taking a simple bite of food," she said. "When I would finally muster enough courage to eat food I wasn't familiar with, my gag reflex would instantly trigger and it would send me into an anxiety attack." According to Heather, she currently has "aversions to specific textures and tastes."
ARFID can pose serious health risks
Everyone has something they don't like or won't eat, but avoiding a small number of foods typically poses no serious health concerns. But for those with ARFID, their dietary options are so limited that this poses serious risks to their health.
According to Medical News Today, these dangers include malnutrition, significant weight loss that leads to low blood pressure and slowed heart rate, micronutrient deficiencies, low bone mineral density, and a dependence on external feeding options such as feeding tubes or nutritional supplements. In addition, serious nutritional deficiencies can cause the body's systems to slow down to save energy. This poses harmful effects on one's health. And, with troublesome symptoms associated with ARFID such as insomnia and impaired immunity, it's clear that the disorder can be harmful to your health over time (per the National Eating Disorders Association).
One woman named Heather shared with Medical News Today the ways which ARFID impacted her health. "After years of having ARFID, I am only just now starting to see the physical health impacts of it," she wrote. "Slightly-elevated cholesterol, lower iron intake, and some recent weight gain have been the primary ways in which ARFID has shown it could be impacting my physical health lately."
How is ARFID diagnosed?
With some symptoms of ARFID overlapping with other disorders (per the Child Mind Institute), diagnosing individuals with ARFID can be difficult.
To officially diagnose someone with ARFID, a medical or mental health professional must conduct a clinical assessment and diagnostic psychiatric interview. The assessment should determine whether an individual's food aversion is based on the sensory characteristics of food, lack of interest in food or eating, or fear of aversive consequences. According to the National Eating Disorders Association, a major nutritional deficiency must be present for an official diagnosis to be made. This is based on obvious weight loss, dependence on external feeding or nutritional supplements, or, in children, being unable to meet growth requirements for their age.
A diagnosis will also be made based on whether the symptoms can or cannot be explained by the presence of another mental or eating disorder, by the lack of available food, or by religious or cultural practices.
ARFID may have more than one cause
While an exact cause of ARFID is unknown, a literature review from Current Psychiatry Reports suggests several possible causes. These include taste perception sensitivity, decreased activity within the appetite-regulating centers in the brain, and an earlier traumatic experience as a child involving food or eating that results in a phobia.
Medical professional Kim DiRé, LPC, MEd, SEP, DBH, elaborated on the latter cause in a blog post from the National Eating Disorders Association. "Case studies show that many people with ARFID have suffered from a traumatic childhood experience," she explained. These might include choking incidents as a young child, feeding issues as a baby, or having an umbilical cord wrapped around a baby's neck during birth. ARFID can even be linked to trauma while still in the womb if the mother experiences an accident or undergoes a difficult experience while giving birth.
Many people with ARFID also have ADHD or autism spectrum disorder
Research (via Current Psychiatry Reports) shows that many individuals diagnosed with ARFID also have other disorders, most commonly autism spectrum disorder and attention deficit hyperactivity disorder (ADHD).
ADDitude magazine explains that, with sensory sensitivities being a common feature of ADHD and autism spectrum disorder, it's understandable that individuals with these diagnoses may be more likely to also have an ARFID diagnosis. In fact, those with ARFID are more likely to have another related disorder than those with any other type of eating disorder. One study on children with ARFID found that 13% of participants were also diagnosed with autism spectrum disorder.
Examples of sensory sensitivities include being extremely sensitive to smells, refusing to eat foods that are mushy or crunchy, for example (as Child Mind Institute points out), or putting up a fight if unliked foods are on the same plate or table as food they do eat.
Those with ARFID likely also struggle with anxiety conditions or mood disorders
According to a paper published in Current Psychiatry Reports, generalized anxiety disorder is another mental health condition that commonly occurs in those diagnosed with ARFID. Heather, who shared her experience with ARFID, wrote about her own co-occurring diagnosis. "Not long after receiving my ARFID diagnosis and seeing an eating disorder specialist, I was diagnosed with an anxiety disorder," she said (via Medical News Today). "I never really noticed symptoms of anxiety until my collegiate years, but I didn't receive an official diagnosis until I was 27 or 28."
Because children with ARFID often display rigid behaviors and ritualistic eating habits, it's common for them to also be diagnosed with obsessive-compulsive disorder (OCD), per the Child Mind Institute. A published literature review from Current Problems in Pediatric and Adolescent Health Care reported increased rates of generalized anxiety disorder and OCD in individuals with ARFID. "Emetophobia, or fear of vomiting, is the main condition under OCD that might be confused with ARFID," said Jerry Bubrick, PhD, director of the Obsessive-Compulsive Disorder Service at the Child Mind Institute.
ARFID has a potential link to neurogastroenterology or 'mind-gut' conditions
Research on ARFID points to a link with neurogastroenterology or "mind-gut" conditions, as researchers have found a strong connection between the brain and the stomach or gut (via Johns Hopkins Medicine). This can explain why people with ARFID commonly experience gastrointestinal problems, including bloating, constipation, upset stomach, and diarrhea.
What's more, researchers are even finding evidence that irritation in the gastrointestinal system may send signals to the central nervous system that trigger mood changes. "For decades, researchers and doctors thought that anxiety and depression contributed to these problems. But our studies and others show that it may also be the other way around," according to Jay Pasricha, MD, director of the Johns Hopkins Center for Neurogastroenterology.
Based on the findings of a retrospective study published in Clinical Gastroenterology and Hepatology, researchers from Massachusetts General Hospital recommend that neurogastroenterology patients be screened for ARFID.
How can ARFID be treated?
Several treatment options are available for ARFID based on individual needs. However, because ARFID is such a recent diagnosis, researchers are still determining the best ways to treat it. "There are a couple of pilot studies, treatment development studies, but there are no randomized clinical trials," Daniel Le Grange, PhD, director of the Eating Disorders Program at the University of California, San Francisco, told the Child Mind Institute.
Per WebMD, cognitive behavior therapy is a common long-term treatment to help alter patients' feelings and attitudes towards food and eating. Some people see great results from working with a psychologist or other mental health professional to treat related mental health conditions that could be contributing to their eating issue. Depending on the severity of the case, short-term treatment options include customized meal plans from a dietitian, prescription nutritional supplements, speech therapy for help with motor skills that aid in eating, and prescription medication to reduce anxiety or improve appetite.
For parents of young children struggling with ARFID, a short-term group cognitive-behavioral therapy program at Children's Hospital of Philadelphia called the Picky Eaters Clinic may prove helpful. "In the Clinic, parents are taught to act as behavioral therapists who promote long-term improvements in food acceptance and positive mealtime behaviors," explained Katherine Dahlsgaard, PhD, ABPP, clinical director of CHOP's Anxiety Behaviors Clinic.