Avoidant/Restrictive Food Intake Disorder

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the designation of a newly defined eating disorder called avoidant/restrictive food intake disorder, also referred to as ARFID. This disorder is characterized by an "avoidance or restriction of food intake" to the extent that it becomes "clinically significant [in the] failure to meet requirements for nutrition or insufficient energy intake through oral food intake."

The criteria specifies that this inadequacy cannot be a consequence of another eating disorder, medical condition, food insecurity, or a cultural observance. However, it is possible for ARFID to co-exist with other conditions or disorders, (except for anorexia nervosa and bulimia nervosa), assuming that criteria have been met and the disturbance in eating requires further clinical attention.

According to the DSM-5, one or more of the following four features must be present for the diagnosis of ARFID:

• Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
• Significant nutritional deficiency
• Dependence on enteral feeding or oral nutritional supplements
• Marked interference with psychosocial functioning

The Academy of Nutrition and Dietetics Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders indicates it may be easy to miss the signs and symptoms of ARFID due to the lack of body dissatisfaction that is present with other eating disorders. In addition, many studies have focused on younger age groups, bringing up additional questions about whom may be affected by this condition.

Although RDNs are unable to provide clinical diagnoses, it may be difficult to distinguish, for example, when ARFID may be a separate disorder, rather than a childhood presentation of "picky eating" or when an adult's fear of swallowing is attributed to an anxiety disorder. Anxiety disorders are common among those with ARFID, with a fear of consuming a specific food or group of foods being a predominant phobia, rather than fear of gaining weight.

According to the SOP and SOPP in Eating Disorders, the RDN reviews this resource "to identify needed competence for recognizing the symptoms that suggest an eating disorder and to best support interprofessional collaboration for development of an appropriate plan of care." This will vary depending on individual patient needs, including type of eating disorder being treated for.

An evidence-based approach, along with clinical judgment, is warranted when assessing the significance of a patient's weight status and the degree of nutritional deficiency, as early detection and intervention are both highly desirable in the treatment of eating disorders. Any nutrient imbalances and dehydration should be addressed and a balanced eating pattern promoted.

Adults may benefit from cognitive behavioral therapy, hypnotherapy and support groups to help manage anxiety surrounding food. Whereas children and adolescents may find it beneficial to use a home-based treatment method to focus on desensitization of trigger foods. Competence regarding the complexities involved in feeding and eating disorders and the age-appropriate nutrient requirements will especially aid in the recovery of patients diagnosed with ARFID, regardless of their life stage.

References:

1. Feeding and Eating Disorders. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA: American Psychiatric Press, 2013:329-338.
2. Norris ML, Spettigue WJ, Katzman DK. Update on eating disorders: current perspectives on avoidant/restrictive food intake disorder in child and youth. Neuropsychiatr Dis Treat. 2016 Jan 19;12:213-8. doi: 10.2147/NDT.S82538. eCollection 2016.
3. Hackert AN, Kniskern MA, Beasley TM. Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders. J Acad Nutr Diet. 2020;120(11):1902-1919.e54.
4. Hay P, Mitchison D, Collado AEL, González-Chica DA, Stocks N, Touyz S. Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population. J Eat Disord. 2017;5:21.
5. Escott-Stump, S. (2022). Avoidant/Restrictive Food Intake Disorder. Nutrition & Diagnosis Related Care Nutrition & Diagnosis Related Care (9th Edition., pp 347-349). Academy of Nutrition and Dietetics.