Purpose of Review
To review the literature pertaining to the assessment and treatment of avoidant/restrictive food intake disorder (ARFID) ten years following its introduction to
DSM-5.
Recent ...Findings
Several structured clinical interviews for assessing ARFID have been developed, each with its own strengths and limitations. There is no clear leading self-report measure for tracking treatment progress and outcome in ARFID. Medical assessment is comprised of examining anthropometrics, vitamin deficiencies, and other comorbidities. To date, several studies have reported on cognitive behavioral therapy, family-based treatment, and other approaches to the treatment of ARFID. These treatments appear promising; however, they rely on data from clinical case series and very small randomized controlled trials.
Summary
Several promising assessments and treatments for ARFID are in the early stages of research. Yet, controversies remain. These include (a) overlap with criteria for pediatric feeding disorder; (b) the optimal method for assessing nutrient deficiencies; (c) disciplines involved in treatment. Future research innovation is necessary to improve the psychometric properties of ARFID assessments and evaluate treatment efficacy with larger samples and randomized designs.
Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, ...management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.
Objective
Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is ...defined.
Method
In September 2018, a small multi‐disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM‐5 ARFID diagnostic criteria to guide research in this disorder.
Results
By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment.
Conclusions
This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.
•This review provides the first full systematic outline of the ARFID literature.•Though evidenced as a distinct clinical entity, there are pressing knowledge gaps.•Four areas of focus for ARFID ...research in the next five years are proposed.•Of particular importance is the need to better characterise its varied presentation.
Avoidant/restrictive food intake disorder (ARFID) was recently introduced to psychiatric nosology to describe a group of patients who have avoidant or restrictive eating behaviours that are not motivated by a body image disturbance or a desire to be thinner. This scoping review aimed to systematically assess the extent and nature of the ARFID literature, to identify gaps in current understanding, and to make recommendations for further study. Following an extensive database search, 291 unique references were identified. When matched against pre-determined eligibility criteria, 78 full-text publications from 14 countries were found to report primary, empirical data relating to ARFID. This literature was synthesised and categorised into five subject areas according to the central area of focus: diagnosis and assessment, clinical characteristics, treatment interventions, clinical outcomes, and prevalence. The current evidence base supports ARFID as a distinct clinical entity, but there is a limited understanding in all areas. Several possible avenues for further study are indicated, with an emphasis placed on first parsing this disorder's heterogeneous presentation. A better understanding of the varied mechanisms which drive food avoidance and/or restriction will inform the development of targeted treatment interventions, refine screening tools and impact clinical outcomes.
Avoidant/restrictive food intake disorder (ARFID) is a feeding and eating disorder with evidence for distinct but overlapping presentations characterized by avoidance of eating or narrow dietary ...range related to poor appetite, selective eating, or fear of aversive consequences of eating. The current paper describes a flexible, cognitive-behavioral, family-oriented treatment approach that has been applied to each of these ARFID presentations within a larger partial hospitalization program (PHP) for eating disorders. We provide composite case examples for the presentations and retrospective outcome data on a sample of 81 patients treated with the protocol. Overall, patients with ARFID exhibited significant increases in body weight and the number of foods accepted, and significant decreases on measures assessing food fears, oral control behavior, anxiety, and depression. At baseline, patients with co-occurring poor appetite and selective eating exhibited significantly lower body weight than those with fear of aversive consequences, while the latter group of patients were eating significantly fewer foods and feared a larger number of foods according to parent report. Patients with the fear of aversive consequences presentation also experienced greater increases in the number of foods they were willing to eat and greater decreases in the number of foods they feared over the course of treatment relative to the other two groups. Our findings provide preliminary support for the effectiveness of our family-centered, cognitive-behavioral PHP for children and adolescents with ARFID. Future studies with more sophisticated methods, including randomized controlled designs and ARFID-specific measures, are recommended to help establish evidence-based psychosocial interventions for this clinical population.
•A family-centered cognitive and behavioral treatment protocol for the primary presentations of avoidant/restrictive food intake disorder (ARFID) with case examples.•All ARFID presentation groups improved on symptom measures related to weight, food acceptance, anxiety, depression, and oral control over the course of treatment.•Fear-type ARFID patients came to treatment eating fewer foods and fearing a wider range of foods than patients with other primary ARFID presentations.•Fear-type ARFID patients left treatment at a healthier weight and with a wider range of acceptable foods than those with combined appetite disturbance and low variety.•Fear-type ARFID patients may have a better long-term prognosis and need less ongoing outpatient treatment than their counterparts with more chronic ARFID subtypes.
Avoidant/restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder category in DSM-5 characterized by extreme food avoidance/restriction. Much is unknown about ARFID, ...with limited understanding of its prevalence and comorbidities in general pediatric populations. This study aimed to classify ARFID prevalence and characteristics in children within the Generation R Study, a population-based Dutch cohort (N = 2,862).
ARFID was assessed via an Index that comprised parent-reported questionnaires and researcher-assessed measures of picky eating, energy intake, diet quality, growth, and psychosocial impact, all in the absence of body/weight dissatisfaction to align with DSM-5 criteria. Parents also reported on child appetitive traits and emotional/behavioral problems (eg, anxiety, depression, attention problems).
Using DSM-5–based categorization, 183 (6.4%) of 2,862 children were classified as presenting with ARFID symptoms. Compared with children not exhibiting symptoms, children classified with ARFID symptomatology expressed other avoidant eating behavior, including decreased enjoyment of food (d = −1.06, false discovery rate–corrected p pFDR < .001), increased satiety responsiveness (d = 1.06, pFDR < .001), and emotional undereating (d = 0.21, pFDR < .01), as well as more emotional problems, including withdrawn/depressed (d = 0.38, pFDR < .001), social problems (d = 0.34, pFDR < 0.001), attention problems (d = 0.38, pFDR < .001), anxiety (d = 0.30, pFDR < .001), obsessive/compulsive problems (d = 0.15, pFDR < .05), and autistic traits (d = 0.22; pFDR < .05). Associations did not differ by sex.
This is the first large-scale community-based study to characterize ARFID and to demonstrate that ARFID symptom classification is common in children aged ≤10 years. Findings suggest that appetitive, emotional, and behavioral comorbidities may underlie or reinforce the presentation of ARFID.
We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. Diverse cell lines and/or genomic datasets were not available. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. We actively worked to promote sex and gender balance in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.
The objective of this study was to identify the prevalence of avoidant/restrictive food intake disorder (ARFID) in patients with celiac disease (CD) and assess metabolic complications, disease ...control, diet adherence, and correlation with symptom and quality-of-life metrics.
This was a retrospective study of 137 adult patients with CD who completed an ARFID survey in the CD clinic between 2018 and 2020. Demographics, clinical results, standardized diet assessment, and results of Celiac Disease Symptom Diary and Impact of a Gluten-free Diet Questionnaire were reviewed. The primary outcome measured was the rate of suspected ARFID based on patient-reported survey responses.
Seventy-eight patients (57%) met suspected ARFID criteria. There were no differences in age, gender, body mass index, micronutrient deficiencies, or bone disease in those with or without ARFID. Patients with ARFID did not have a difference in biopsy activity or better adherence to a gluten-free diet compared with non-ARFID patients. Food and social burden on Impact of a Gluten-free Diet Questionnaire was most predictive of ARFID.
ARFID is common and has a high impact in patients with CD. Although some eating behavior is certainly due to their CD, there was no distinct difference in disease control between those with or without suspected ARFID, suggesting these maladaptive behaviors are not necessary for disease control. We did not find increased metabolic complications, but this was a 2-year snapshot. We need to further understand the social and food impacts on patients who score high on this survey to prevent further deficiencies and impaired, long-term detrimental eating behaviors.
Evaluate clinical characteristics at initiation, during, and at discontinuation of care for patients with eating disorders regardless of reason for discontinuation of care.
A chart review of 279 ...patients who presented to the Division of Adolescent Medicine of Cohen Children's Medical Center (Northwell Health, New York) between May 1, 2014 and April 30, 2015. Demographics and clinical information including anthropometry, last menstrual period (LMP), caloric intake, eating disorder behaviors, length of illness, DSM-5 eating disorder diagnosis was collected from 2734 visits.
45% of patients had Anorexia Nervosa (AN), 24% had Atypical Anorexia Nervosa (AAN), 15% had Bulimia Nervosa/Purging Disorder (BN/PD), and 17% had Avoidant Restrictive Food Intake Disorder (ARFID). Patients on average were sick for 18 months and lost 20 pounds prior to presentation. Physicians indicated they wanted patients to remain in active treatment in approximately 40% of cases where care was discontinued. The factors, used to predict which patients would have an unsuccessful vs successful outcome (defined as needing vs not requiring frequent care), were analyzed. A history of diet-pill use, purging, and exercise predicted an “unsuccessful outcome” (p = 0.02, p = 0.005, p=0.03, respectively). 32% of the 202 menarchal females lost their menses prior to treatment, and 54% had resumption of menses during treatment.
Previous studies report high dropout rates in treatment of eating disorders across various treatment modalities and focus on those who remain in care. Here outcomes for all patients evaluated and treatment in an adolescent medicine care model are presented and show that a sizable portion, 37%, of those who drop out are recommended to stay in active treatment and only approximately 30% complete treatment. This finding supports an adolescent care model for eating disorder treatment and highlights that most adolescent patients go on to do well after leaving treatment, even if they left care earlier than recommended.
This study is the first genetically-informed investigation of avoidant/restrictive food intake disorder (ARFID), an eating disorder that profoundly impacts quality of life for those affected. ARFID ...is highly comorbid with autism, and we provide the first estimate of its prevalence in a large and phenotypically diverse autism cohort (a subsample of the SPARK study,
N
= 5,157 probands). This estimate, 21% (at a balanced accuracy 80%), is at the upper end of previous estimates from studies based on clinical samples, suggesting under-diagnosis and potentially lack of awareness among caretakers and clinicians. Although some studies suggest a decrease of disordered eating symptoms by age 6, our estimates indicate that up to 17% (at a balanced accuracy 87%) of parents of autistic children are also at heightened risk for ARFID, suggesting a lifelong risk for disordered eating. We were also able to provide the first estimates of narrow-sense heritability (h
2
) for ARFID risk, at 0.45. Genome-wide association revealed a single hit near
ZSWIM6
, a gene previously implicated in neurodevelopmental conditions. While, the current sample was not well-powered for GWAS, effect size and heritability estimates allowed us to project the sample sizes necessary to more robustly discover ARFID-linked loci via common variants. Further genetic analysis using polygenic risk scores (PRS) affirmed genetic links to autism as well as neuroticism and metabolic syndrome.
This publication addresses the characteristics, health and nutrition implications, and medical nutrition therapy recommendations for Avoidant/Restrictive Food Intake Disorder (ARFID). Written by Lily ...Tucciarone, Sara Murphy, and Wendy J. Dahl, and published by the UF/IFAS Food Science and Human Nutrition Department, December 2022.
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