Avoidant/Restrictive Food Intake Disorder (ARFID)

Avoiding or restricting eating can have significant effects on the body, including substantial weight loss and nutritional deficiencies. People with avoidant-restrictive food intake disorder (ARFID) deny their bodies the nutrients to function correctly. Avoidant/restrictive food intake disorder can affect every system of the body, creating a wide range of symptoms, including but not limited to the symptoms below. 

Cardiovascular symptoms

Cardiovascular symptoms result from an imbalance of electrolytes brought on by malnutrition. Deficiencies in potassium, sodium, and chloride can all have significant effects on the heart, which can lead to the following:

• Low heart rate
• Low blood pressure
• Irregular heartbeat
• Heart failure

Gastrointestinal symptoms

Food restriction can slow digestion, affecting how the stomach empties into the small intestine and how the entire GI system functions. Slowed digestion can cause the following symptoms in avoidant/restrictive food intake disorder: 

• Stomach pain
• Bloating
• Nausea
• Vomiting
• Fullness after eating only a small amount of food
• Constipation
• Blood sugar fluctuations
• Pancreatitis

Neurological symptoms

Electrolytes like potassium, sodium, calcium, and chloride are also crucial in the neurological system as the brain uses them to send signals through the nerves to the rest of the body. When there is an electrolyte imbalance, it can lead to many neurological symptoms, including:

• Difficulties staying awake
• Concentration problems
• Dizziness or fainting, especially upon standing
• Sleep disturbances
• Numbness and tingling in extremities
• Muscle cramping
• Seizures

Endocrine symptoms

The body uses cholesterol and fat to produce many hormones needed to function. Without enough calories and fat, hormones may be affected, which can cause various symptoms. Sex hormones may be affected by a lack of nutrition from ARFID, which can cause: 

• Menstruation that is irregular or stops altogether
• Bone loss
• Increased risk of bone fractures and breaks
• Insulin resistance potentially leading to type 2 diabetes
• Drop in core body temperature leading to cold sensitivity

If thyroid hormone levels are affected, symptoms may include: 

• Fatigue
• Difficulty tolerating cold weather
• Muscle pain
• Joint pain
• Dry skin
• Thinning hair

Other avoidant/restrictive food intake disorder symptoms may involve: 

• Dressing in multiple layers to stay warm or hide weight loss
• Reporting vague gastrointestinal problems around mealtimes with no known cause 
• Dramatically restricting types of food eaten 
• Eating only certain textures
• Having picky eating that progressively worsens
• Fears of vomiting or choking
• Lack of interest in food
• Lack of appetite
• Developing fine hair on the body
• Thinning of hair on the head
• Poor wound healing

The exact cause of avoidant-restrictive food intake disorder (ARFID) is unknown. Researchers believe that the interaction of biological, psychological, medical, and environmental factors may contribute to someone developing ARFID. 

Subcategories of avoidant/restrictive food intake disorder

Some subcategories of this condition have emerged, showing that factors like selective eating since early childhood, gastrointestinal symptoms, anxiety, food allergies, low interest in eating, sensory characteristics of food, and traumatic experiences can all contribute to someone developing ARFID. Cultural factors may also play a role, including family eating style, exposure to healthy eating patterns, and various foods available in the local environment. 

Body image does not seem to be a factor in ARFID. Unlike some other eating disorders like bulimia nervosa or anorexia nervosa, where fear of gaining weight is part of the diagnostic criteria, ARFID is specifically distinguished by an aversion or avoidance of food and eating. However, people with ARFID may experience shame and embarrassment due to weight loss or symptoms.

Avoidant-restrictive food intake disorder (ARFID) has only been a diagnosis since 2013, so limited studies have been done to develop treatment strategies, and no research-backed guidelines are in place. Treatment often depends on the severity of the symptoms. Below are a few options. 

Medication

There are no trials supporting the use of medication for treating ARFID. However, some medications have limited evidence suggesting their benefit to improve appetite and help alleviate other psychiatric symptoms, such as anxiety or depression. Some people with ARFID who are significantly underweight may benefit from cyproheptadine or low-dose olanzapine to increase hunger and facilitate eating. However, speak to your doctor before starting, changing, or stopping a medication for any condition. 

One recent study on children under six years old with various feeding difficulties had more significant improvements in weight gain and positive changes in feeding behaviors than those who didn’t take the medication. However, some people with ARFID might not experience these benefits. Individuals can develop drug tolerance quickly, which may necessitate taking a break from the medication every month.

Other treatment options for avoidant/restrictive food intake disorder

Some people with ARFID, particularly children, may require day treatment or inpatient treatment. Supplementing with oral nutritional formula or tube feedings to ensure the person receives the nutrition they need and medical monitoring of hydration and weight gain during refeeding can be vital.  

Tube feeding is often temporary, so weaning from tube feeds can also be a critical part of treatment. In this treatment, the goal may be to reduce the calories given via tube feed to stimulate the desire to eat. Studies on this approach to treatment have been done in children, and there is a need for more short and long-term research, including looking at older patients and those with less severe cases of ARFID.

While tube feeding may be a late intervention for those with anorexia nervosa, it may be a first-line treatment for ARFID. Some research indicates that people with ARFID are more likely to need tube feeds than those with anorexia to meet their calorie requirements, showing how severe refusing food can be in people with this condition. ARFID can lead to complications, including death.  

Self-care

Self-care may not be effective at alleviating symptoms of ARFID, but it may relieve the stress that comes with it. Some self-care practices to try include the following:

• Eat healthy, regular meals
• Get regular exercise
• Stay hydrated
• Try a relaxing activity
• Stay connected to friends and family

A study looking at cognitive-behavioral therapy for treating avoidant-restrictive food intake disorder was interrupted by the COVID-19 pandemic, which provided a unique opportunity for researchers to look at the results of online treatment in this population. Researchers found that video delivery of treatment has several benefits over in-person treatment, including food availability in the home, which was helpful for food preparation and exposure addressed in-session. Online treatment through platforms like BetterHelp was also more convenient for people to attend, contributing to lower drop-out rates. 

The National Eating Disorders Association offers unique information about ARFID and first-hand accounts of people who have recovered from the condition. 

The National Association of Anorexia Nervosa and Related Disorders (ANAD) hosts virtual support groups for various communities and demographics.

The National Institute on Mental Health has information about ARFID and other eating disorders, including digital shareables about eating disorders, to start a conversation and spread awareness.

Cognitive-behavioral therapy for avoidant-restrictive food intake disorder (CBT-AR) is a therapeutic modality tailored to this mental health disorder. However, research about its efficacy is still underway. One recent study described the stages of the CBT-AR process. In stage one, participants receive psychoeducation about ARFID and begin self-monitoring their food intake and weight gain. They work on establishing a regular eating schedule while attempting to increase food variety or volume. 

In stage two, they learn about the effects of nutritional deficiencies and select foods that increase the intake of foods from all food groups to resolve nutritional deficiencies and gain weight. In stage three, patients work on addressing their behaviors. For example, those with sensory aversions choose five new foods to try per session. In stage four, clients create a plan to prevent relapse. Adults in this study made significant progress—the post-treatment remission rate was 47%. When a similar experiment was done with children and adolescents, it was 70%.

Because ARFID is a relatively new diagnosis, some recent studies are looking at the prevalence and symptoms of the condition. One study found that patients with ARFID tended to be younger than those with other eating disorders, such as anorexia or bulimia. They also had a longer period of symptoms before getting treatment and were more likely to have comorbidities, such as autism spectrum disorder. According to this study, there are differences between ARFID and other eating disorders. In addition to there being no body image disturbance in ARFID, clients may also express a desire to eat more or gain weight.

After attending CBT, 47% of clients achieved full symptom remission

Limited research has been done on the treatment of avoidant-restrictive food intake disorder (ARFID), but a recent study has found that after 20 to 30 sessions of cognitive-behavioral therapy, 47% of clients in the study no longer met the criteria for the disorder.¹

¹Journal of Behavioral and Cognitive Therapy

Below are key statistics on avoidant/restrictive food intake disorder:

• It is challenging to know how many people have ARFID, as it was only added to the DSM-V in 2013. Recent research indicates that it may affect about 3.2% of children aged eight to 13 and as much as 22.5% of patients with eating disorders in pediatric day treatment programs.
• In a recent study looking at the prevalence of ARFID in patients referred to neuro-gastroenterology for GI symptoms, 23.6% had symptoms of ARFID, 6.3% met the DSM-V criteria for an ARFID diagnosis, and 17.3% potentially had ARFID. 
• Research shows that people with ARFID are more likely to have comorbidities. One recent study found that of the patients with ARFID, 58% had an anxiety disorder, and 55% had a comorbid medical condition.
• People with attention-deficit hyperactivity disorder (ADHD) are more likely to have ARFID.

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