By What is ARFID, the new kid on the block?
Are you familiar with ARFID? The term “avoidant restrictive food intake disorder,” or ARFID for short, refers to an eating disorder in which a person either eats a very limited variety of foods (thus not getting enough macro- and micronutrients) or a very low volume of food (thus not getting enough calories). ARFID causes many people to limit their food intake, both in terms of quantity and variety. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Fifth Edition, which was released in 2013, formally recognized ARFID as a diagnostic of food and eating disorders (it is also included in ICD-11 published in 2022). Nearly ten years later, most medical professionals may have heard of the term ARFID, but many are still unsure of the specifics of this diagnosis.
Although ARFID is a new word, the problem is not.
Even though this particular kind of disordered eating has been present for a long time, the official diagnosis of ARFID was not assigned to it until 2013. Picky eating, feeding disorders, eating disorders not otherwise specified (EDNOS), and anxiety disorders not otherwise specified were some of the labels and diagnoses used to characterize it before that. Some individuals with an eating disorder similar to ARFID may have been labeled with anorexia nervosa in the absence of a better treatment option, despite not limiting their food intake because they desired to be thin or were concerned about gaining weight.
Why do individuals with ARFID limit or avoid certain foods?
ARFID patients restrict or avoid meals for non-weight- and shape-related causes. These are typically caused by three factors:
- a low appetite and lack of interest in food;
- a fear of choking, vomiting, allergic reactions, or stomach pain; and
- a strong dislike of certain food sensory attributes, such as texture, taste, appearance, smell, or temperature, which results in disgust towards these foods.
Resulting from avoiding or restricting food
Crucially, ARFID should only be recognized in cases when severe physical repercussions resulting from food restriction or avoidance occur, such as failure to gain weight or loss of weight, nutritional inadequacies, or a need for enteral feeding or nutritional supplements. If the avoidance or limitation of eating results in significant psychosocial impairment, such as social exclusion, bullying, or inability to attend work or school, it is also regarded as a major consequence.
Picky vs. ARFID eating
It can be challenging for medical professionals to distinguish ARFID from selective or picky eating, which is rather common because many people have food preferences. It’s crucial to understand that ARFID varies from picky eating in terms of the severity and outcomes of food avoidance. Picky eaters do not experience the serious physical and mental problems that people with ARFID have as a result of their eating disturbance. ARFID encompasses more than just selective eating; for instance, some individuals with the disorder are not picky eaters at all; rather, they simply have a hard time eating enough since they feel full after just a micro biting.
Many ARFID individuals are not underweight.
It’s also critical to understand that a person with ARFID may exhibit one or more of the other physical or psychological symptoms without being underweight. Consider Robert, a young boy who only enjoys eating items that fall within the white, beige, and brown color range. Fries, potatoes, rice, crackers, chips, pasta, and ice cream are among the few foods he will eat. He eats a lot of these meals because he enjoys them. As a result, Robert consumes adequate—possibly even excessive—calories, but because he doesn’t eat any fruit, vegetables, or meat, he is vitamin and protein-deficient. Overweight individuals should not rule out the possibility of an ARFID diagnosis because the weight of those with the disorder varies widely.
ARFID can affect anyone at any age.
The fact that ARFID can be identified at any age is another crucial aspect of the condition. people can also suffer from ARFID, even though it appears to begin in childhood most often. People with ARFID may have had eating disorders similar to ARFID since childhood.
How widespread is RFID?
Although the exact prevalence of ARFID in the general population is still unknown, it is most likely between 1% and 5% in both adults and children. This suggests that there are currently between 100,000 and 500,000 people in Sweden who have ARFID, albeit none of them have received a formal diagnosis because ICD-11 has not yet been adopted in that country. Large sample sizes and established screening instruments are required to ascertain the prevalence of a disorder in the general population.
We have created a tool to record the prevalence of ARFID in Japanese children aged 4–7, as there are currently no parent-reported screening techniques available for the disorder. Boys made up 45% of the 1.3% of children who tested positive for ARFID. 1. The same screener is still being used in an ongoing study in which we tested about 700 2.5- and 4-year-old children who were visiting 20 child health clinics (BVCs) in the Fyrbodal region north of Gothenburg for routine check-ups.
To confirm the diagnosis, children who tested positive for ARFID had a clinical interview. We aim to determine the prevalence of ARFID in preschool-aged children as well as the accuracy of this new screener in identifying ARFID cases.
ARFID at the confluence of neurodevelopmental problems, anxiety, and eating disorders
Despite being classified as a feeding and eating problem, ARFID shares many characteristics with neurodevelopmental disorders (NDDs), including high heredity, early onset, and stability throughout life. We discovered that ARFID has a very high heritability (around 80%) in a recent (not yet published) twin study, which is equivalent to the heredity of ADHD and autism. NDDs and ARFID also frequently co-occur.
We discovered that children in the Japanese sample who had early neurodevelopmental issues were more likely to screen positive for ARFID between the ages of 4 and 7. These issues included issues with language and communication, social interaction, attention, concentration, and sleep. ARFID was found in 28% of children from a low-resource, multiethnic area who were diagnosed with autism before the age of six in another study, and many more had feeding issues that did not fit the criteria for ARFID (only 24% had no feeding issues at all).
This study looked at ARFID in children diagnosed with autism before the age of six. But anxiety disorders and ARFID are also tightly related. For instance, a specific phobia (of food) could be used for the fear-based presentation of ARFID. Additionally, there is a significant rate of comorbidity between anxiety disorders and ARFID patients: 35-72% of these individuals have a diagnosed anxiety disorder, with social anxiety and generalized anxiety disorder being the most frequent.
An ARFID is a general diagnostic.
ARFID is a highly heterogeneous diagnosis, as you have undoubtedly realized by now, making it more difficult to determine its origins and develop a treatment plan. More than the previously recognized diagnoses for eating disorders (such as bulimia nervosa and anorexia nervosa), ARFID is a general term that covers a broad spectrum of symptom profiles and intensities. People of any age, gender, or weight are affected.
Either an acute onset, which is more common in people who have a fear of things like choking, or a long-term onset, which is more common in those who present with low interest and who avoid sensory stimuli. Furthermore, there is a high level of somatic comorbidity, and the dietary restriction is based on three distinct but frequently co-occurring motives (e.g., acid reflux, constipation, food allergies, and cardiac issues).
Therefore, it’s critical to detect somatic diseases that may exacerbate eating disorders or even account for symptoms like weight loss when diagnosing ARFID (in the latter scenario, ARFID would not be recognized). Thus, ARFID is also an excluding diagnosis. That is to say, if an individual drastically restricts their food intake and this has major physical and/or psychological repercussions, they would only receive an ARFID diagnosis if their food restriction cannot be attributed to underlying medical issues, fear of gaining weight, or a drive to be thin.
Better ARFID care is desperately needed.
The fact that the healthcare system now provides very little help to people with ARFID and their families is a serious issue. Unfortunately, there are no national treatment recommendations, and ARFID treatment has not been systematically included in Swedish healthcare. Individuals with ARFID frequently switch between medical specialties (pediatrics, psychiatry, gastrointestinal, etc.) with ambiguous diagnoses and treatment regimens.
Furthermore, it might be challenging to get therapy for ARFID even after a diagnosis. Many specialist eating disorder units in Sweden are not yet commissioned to treat patients with ARFID, despite the obvious fact that they should be among the primary providers of care for ARFID patients.
For the patients and their families, this is a stressful scenario. We now know enough about ARFID to begin providing care for this patient group more widely, even if evidence-based treatments are still being developed and assessed (see suggested books). Examples of such treatments include cognitive behavioral therapy and family-based treatment for ARFID. Research on what is ARFID is desperately needed, but we must also put our newfound knowledge into practice so patients and their families can take advantage of it!
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