ARFID

What is Avoidant/Restrictive Food Intake Disorder?

Avoidant restrictive food intake disorder, more commonly known as ARFID, is a condition characterised by the person avoiding certain foods or types of food, having restricted intake in terms of overall amount eaten, or both.

Anyone of any age can have ARFID. It occurs in children, teenagers and adults. Although people with ARFID may lose weight or have low weight, this is not a criteria for ARFID. It can occur at any weight and varies in different people.

Someone might be avoiding and/or restricting their food for a number of different reasons. The most common are the following three reasons. You might see these referred to as subtypes of ARFID:

They might be very sensitive to the taste, texture, smell, or appearance of certain types of food, or only able to eat foods at a certain temperature. This can lead to sensory-based avoidance or restriction of intake.

They may have had a distressing experience with food, such as choking or vomiting, or experiencing significant abdominal pain. This can cause the person to develop feelings of fear and anxiety around food or eating, and lead to them to avoiding certain foods or textures. Some people may experience more general worries about the consequences of eating that they find hard to put into words, and restrict their intake to what they regard as ‘safe’ foods. Significant levels of fear or worry can lead to avoidance based on concern about the consequences of eating.

In some cases, the person may not recognise that they are hungry in the way that others would, or they may generally have a poor appetite. For them, eating might seem a chore and not something that is enjoyed, resulting in them struggling to eat enough. Such people may have restricted intake because of low interest in eating.

It is very important to recognise that any one person can have one or more of these reasons behind their avoidance or restriction of food and eating at any one time. In other words, these examples are not mutually exclusive. And sometimes, there is no clear reason or event that has led to someone developing ARFID. This means that ARFID might look quite different in one person compared to another. Because of this, ARFID is sometimes described as an ‘umbrella’ term – it includes a range of different types of difficulty. Nevertheless, all people who develop ARFID share the central feature of the presence of avoidance or restriction of food intake in terms of overall amount, range of foods eaten, or both.

ARFID can be present on its own, or it can co-occur with other conditions; those most commonly co-occurring with ARFID are anxiety disorders, autism, ADHD and a range of medical conditions. The eating difficulties someone with ARFID has, can have been present for a very long time, in some cases almost as long as they can remember. In other people, it might have a more recent onset.

ARFID would not be diagnosed in someone who is fasting or chooses not to eat certain foods for religious or cultural reasons alone. Neither would it be diagnosed if there was a lack of available food or certain foods were being avoided because of allergies. A diagnosis of ARFID would also not be given if there is another clear reason for the eating difficulty, such as a medical condition that results in appetite loss or digestive difficulties.

Key aspects of ARFID are that it can have a negative impact on the person’s physical health and as well as on their psychological wellbeing. Children and young people with ARFID may fail to gain weight as expected and their growth may be affected, with a slowing in height increase. When a person does not have an adequate diet because they are only able to eat a narrow range of foods, they may not get essential nutrients needed for their health, development and ability to function on a day-to-day basis. In some people, serious weight loss or nutritional deficiencies may develop, which need treatment. In people whose food intake is very limited, nutritional supplements may be prescribed. In some cases a period of tube feeding may be recommended if physical risk is judged to be high.

Being limited in terms of what they can eat often causes people to experience significant difficulties at home, at school or college, at work and when with friends. Their mood and day-to-day functioning can be negatively affected. Many people with ARFID find it difficult to go out or to go on holiday, and their eating difficulties may make social occasions difficult to manage. They may find it difficult to make new friends or establish close relationships as social eating occasions are often part of this process.

Is ARFID different to anorexia and bulimia?

ARFID is different from anorexia nervosa, bulimia nervosa and related conditions; in ARFID, beliefs about weight and shape do not contribute to the avoidance or restriction of food intake. A diagnosis of ARFID would not be given at the same time as one of these other eating disorders, although it could precede or follow.

Signs of ARFID

Because ARFID includes a range of different types of difficulty that contribute to the avoidance or restriction of food intake, there is a wide range of possible signs and symptoms, not all of which would necessarily occur in one person. Possible signs of ARFID include:

• Eating a reasonable range of foods but overall having much less food than is needed to stay healthy.
• Finding it difficult to recognise when hungry.
• Feeling full after only a few mouthfuls and struggling to eat more.
• Taking a long time over mealtimes/finding eating a ‘chore’.
• Missing meals completely, especially when busy with something else.
• Sensitivity to aspects of some foods, such as the texture, smell, or temperature.
• Appearing to be a “picky eater”.
• Always having the same meals.
• Always eating something different to everyone else.
• Only eating food of a similar colour (e.g. beige).
• Attempting to avoid social events where food would be present.
• Being very anxious at mealtimes, chewing food very carefully, taking small sips and bites, etc.
• Weight loss (or in children, not gaining weight as expected).
• Developing nutritional deficiencies, such as anaemia through not having enough iron in the diet.
• Needing to take supplements to make sure nutritional and energy needs are met.

What to do if you are worried about yourself or someone you care about

If you think you might have ARFID, you should make an appointment to discuss this with your GP. If you are concerned that a family member or friend has ARFID, it is important to talk with them to support and encourage them to seek the right help and support. It is usually best that this help and support is in place as soon as possible after the difficulties have been recognised. You may feel daunted by idea of trying to change your eating, or the person you care about may be scared or may not be as concerned about their eating as others. People with ARFID may not be able to see any possibility that they can ever change their eating behaviours. This may lead to them being reluctant to reach out for help, or saying that everything is okay. However, ARFID can lead to serious malnutrition and be associated with significant impairment to psychological wellbeing, so it is important that they receive this support.

Your first step when seeking help is through your GP or the GP of the person you care about. It could be helpful to go with someone close to you, or suggest that you go to this appointment together if you are concerned about someone else. It is often helpful to go prepared with notes about your concerns and to explain clearly why you think the difficulties are related to ARFID.

If you are taking your child to see the GP, it is always best to explain to them why you are going and what you are concerned about, again taking some prompts or notes to the appointment. For example, think about how long things have been going on and any symptoms or behaviours that you are worried about. If going to the GP is something you are anxious about, you can speak to our Helpline about your worries.

Treatment for ARFID

Due to the varied forms ARFID may take, people may receive treatment in one or more of a number of different types of services from a range of different types of professionals. More research is also needed on evidence-based treatments. Currently, treatment for ARFID is not included in the NICE or SIGN guidelines for eating disorders. This means that the availability of services varies across the UK, however, this certainly does not mean it does not need to be taken seriously.

The GP should still make a referral to the relevant service. Young people may be treated by their local community eating disorders service for children and young people, generic Child and Adolescent Mental Health Services (CAMHS), community paediatric services, in the local acute paediatric service, or by a range of practitioners, including dietitians, speech and language therapists, psychologists and occupational therapists. Adults with ARFID may be treated by specialist eating disorders services, general mental health services (particularly those offering treatment for anxiety), as part of hospital-based liaison work when the ARFID occurs in the context of a chronic medical condition, or by different practitioners.

As knowledge and understanding of ARFID grows in the medical community, new services are being developed, and it is important to try and find the right support for you, or your loved one. Treatment for ARFID is usually best tailored to the needs of the individual, based on the specific nature of the difficulties the person is experiencing and what is considered to be maintaining these. Most often, treatment can be delivered in an outpatient setting. Treatment commonly involves evidence-based treatments such as family-based treatment (for young people), cognitive behavioural therapy, behavioural interventions such as exposure work, and anxiety management training. Sometimes some medication may be suggested, most often to help with anxiety. The person’s physical health should also be monitored and managed, for instance by their GP or a physician or paediatrician. Treatment may also involve nutritional management through support from a dietician, and help with sensory problems.