We all probably have that person in our lives – the one who will only eat a limited selection of foods.
While some of us would consider ourselves as picky eaters, for some people, pickiness can become dysfunctional.
When it gets to an extreme level, avoidant restrictive food intake disorder (Arfid) – a lesser-known eating disorder – can have a severe, lifelong impact on our health and quality of nutrition.
Back in 2019, Arfid gained a lot of attention when a British teen was reported to have suffered irreversible sight and hearing loss after years of only eating a handful of processed foods like potato chips and white bread.
The teen suffered from Arfid because the texture of other foods was difficult for him to tolerate.
Although this is an extreme example, it shows the harm that this eating disorder can cause for those who suffer from it.
It’s inedible for them
Arfid was recognised by the American Psychiatric Association in 2013, making it a fairly new condition.
It’s thought to affect around 5-15% of children and less than 1% of adults with eating problems who are admitted to the hospital.
And it is different from other eating disorders such as anorexia and bulimia.
Rather than weight control as the key factor for developing the condition, people afflicted with Arfid have an inherent fear of food and the act of eating.
While certain foods, sights or smells may evoke disgust or fear in many of us, people with Arfid experience this every day with many foods that almost all of us would consider to be acceptable and palatable.
They have no motivation to change their eating habits as the mental discomfort of adding inedible foods is too difficult to handle.
In general, someone with Arfid will have one or more of the following characteristics:
- Avoiding foods because of their sight, smell or taste.
- A lack of interest in eating or food, or an absence of hunger.
- Not eating enough calories, protein, vitamins or minerals.
- Worry from a parent or child about the limited number and types of food eaten.
Diagnosing Arfid can be difficult, but typically, doctors will look for signs of nutritional deficiencies such as brittle nails and hair, skin changes, bleeding gums or lips, unexplained bruising, changes in eyesight, chronic fatigue, forgetfulness and poor growth.
They will then examine the amount and number of food types the person eats, how long avoidance of certain foods has been a problem, whether the person has lost weight or if their growth is stunted.
They will also look at whether the condition causes distress or interferes with daily life.
Reasons for avoidance
Most patients with Arfid avoid food for one or more of the following reasons:
Patients who fall in this category restrict food not because they have body image or weight gain concerns, but because of past experiences with nausea or abdominal pain while eating.
They restrict food to avoid these symptoms.
Parents often describe children in this category as being “grazers” or “eating like a bird”.
Their symptoms include longstanding low appetite, early satiety (feeling full) and indifference to food.
In these cases, patients’ appetites do not increase sufficiently to meet the increased energy needs of puberty, resulting in a fall of their growth curve.
Some children may lose their appetite in response to feeling scared, stressed or unhappy.
Examples of stressors include anxiety associated with going to school; being bullied or rejected by peers; moving or losing a friend; parental conflict, separation or illness; or physical, sexual or emotional abuse.
Patients in this category are extremely selective of the food that they consume, with their pickiness dating back to an early age.
They often have sensory hypersensitivity that results in profound rigidity involving food.
In many cases, the rigidity extends to the manner in which food is served and to details related to preparation.
These patients will only accept the same limited number of foods prepared in the exact same manner and served in the exact same way.
These extremely rigid picky eaters are challenging to treat and almost always require a multidisciplinary team approach.
Even though picky eating is common in children, this is not the case for children with Arfid.
Physical warning signs of Arfid include:
- Difficulty concentrating
- Dizziness or fainting
- Sleep-related issues
- Stomach cramps and other gastrointestinal complaints
- Cold intolerance
- Menstrual irregularities
Meanwhile, psychological signs of this condition include:
- Limiting food intake to particular textures
- Fear of choking or vomiting
- Lack of interest in food or appetite
- Picky eating that becomes worse
- Complaints of upset stomach or feeling full around mealtimes
Focus on weight gain
In children and adolescents, Arfid can result in patients getting insufficient nutrition that stunts growth (especially in children) and results in drastic weight loss.
Limited research exists to guide clinicians in the treatment of Arfid, although clinical trials are presently underway in the United States and elsewhere.
In many cases, consultation with a feeding or eating disorder specialist is necessary.
Family-based therapy, which is the gold standard treatment for adolescent anorexia nervosa, seems well-suited to the treatment of a proportion of underweight youngsters with Arfid.
This form of therapy focuses on lifting blame, raising the family’s awareness about the dangers of low weight and malnutrition in young people, and educating parents on how to take charge of nutrition and focus on the goal of weight gain.
Using detailed food diaries and weekly weight graphs, the family can play a key role in helping the patient through their food intake and weight gain issues.
For some, receiving individual cognitive behavioural therapy is also beneficial to address anxiety.
The main goal of treatment is to focus on helping the patient gain a healthy weight and ensure that they are getting the proper nutrition to support their physical development and mental wellbeing.
In cases where the diagnosis is unclear, it’s possible to first proceed with a treatment that is focused on weight gain.
The uncertainty can occur if some patients with anorexia nervosa present with low weight, but deny body image concerns.
The final diagnosis will become apparent after the patient has been on treatment for a certain amount of time. Then the appropriate treatment can be given (or continued).
However, more studies are needed to better understand which treatments are most effective for Arfid, as well as the development of eating disorder-specific and Arfid-specific measures and diagnostic instruments.
Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician and gynaecologist, and a functional medicine practitioner. For further information, email firstname.lastname@example.org. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.