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Do you know someone who is a really, really picky eater? Sometimes fussy diners aren't just picky about what they eat. Some picky eaters suffer ARFID, avoidant/restrictive food disorder.

Are you fussy about your food? Or have you been the parent of a picky eater? Sometimes picky eaters just don't have access to wholesome, fresh, tasty food. But some people who are picky about eating live with an eating disorder known as ARFID, or avoidant/restrictive food disorder. ARFID has some distinct dissimilarities with other, better known eating disorders. It does not cause severe weight loss. It does not interfere with development in childhood and adolescence. And it doesn't result in severe dysfunctions of health. But it may still need treatment.

Avoidant/restrictive food disorder is about more than just picky eating

People living with avoidant/restrictive disorders usually have a long list of foods they don't want to eat because they have a strong association between a bad experience and eating a food, or because they don't like the foods' taste, smell, appearance, texture, or provenance. For instance, someone might not like Limburger cheese because it's bitter, it's stinky, it looks like (some term we won't publish), it's slimy, and it comes from cows.  It's possible to be a healthy, well-nourished picky eater, although picky eaters may not be a lot of fun to be around. 

Avoidant/restrictive food disorder describes a state in which "picky eating has gone too far". Children who avoid so many foods that they fail to grow on schedule may have this condition. Adults who live on tea and toast or whose only source of nutrition is a meal replacement beverage like Ensure may have this condition. 

ARFID isn't what happens during fasting for religious purposes. It's not tied up with self-image like anorexia. It's not related to the availability of food. Someone who has an avoidant/restrictive food disorder may also suffer anorexia or bulimia, but the symptoms of ARFID don't occur exclusively in the context of symptoms of those better-known eating disorders.

What causes avoidant/restrictive food disorder?

Sometimes ARFID is a food phobia. A young child has a bad experience of getting sick after eating certain kinds of food, or chokes on food, or witnesses an upsetting incident caused by food. 

Sometimes ARFID results from a gastrointestinal condition, such as irritable bowel syndrome, peptic ulcer disease, Crohn's disease, ulcerative colitis, or gastroesophageal reflux disease (GERD). Children get into the habit of avoiding food because of painful experiences with it. Far less frequently, ARFID develops in adults who have an experience with some extremely painful and/or embarrassing gastrointestinal illness such as "Montezuma's revenge" (traveler's diarrhea) or ischemic colitis. They may say "I'll never eat again" and mean it. 

Avoidant/restrictive food disorder is unlike other eating disorders in that it occurs in more males than other eating disorders, but females still account for 70 percent of cases. It also begins at an earlier age. ARFID is typically first noticed around age 13, while anorexia and bulimia usually are diagnosed at ages 15-1/2 and 16-1/2, respectively. A preteen or a young teen with ARFID has an increased risk of developing anorexia or bulimia as they mature.

The most important reason to treat ARFID is to prevent other, more serious eating disorders from developing later.

What are the symptoms of avoidant/restrictive disorder?

Anyone who has ARFID will reject certain foods, or most foods, because of taste, smell, texture, or appearance. This can be followed by a general loss of appetite and then an absolute refusal to eat. ARFID can be accompanied by other symptoms:

  • 17-18 percent of people who have ARFID will report strange sensory experiences when they eat.
  • 17-18 percent of people who have ARFID will experience nausea.
  • 20-21 percent of people who have ARFID have a generalized anxiety about eating
  • 20-21 percent of people who have ARFID feel full after eating small amounts of food.
  • 26-27 percent of people who have ARFID will have a fear of vomiting.
  • About 35 percent of people who have ARFID have frequent abdominal pain.

People who don't get enough to eat usually also don't get enough to drink. They may become so dehydrated that they develop orthostatic hypotension, passing out when moving from a seated position to a standing position. People in a state of semi-starvation may develop a slow heart rate and low blood pressure. People who have had ARFID for a long time may develop gastroparesis, a sluggish digestive tract, keeping them feeling full, even bloated, and making good nutrition even more difficult.

How do doctors treat avoidant/restrictive food disorder?

There is no medication for ARFID, but because most people who have ARFID also suffer severe anxiety, the doctor will often offer a tranquilizer such as alprazolam (Xanax).

The most important feature of any treatment plan for ARFID is the calorie prescription. The doctor will insist that the patient get enough calories to keep the body from salvaging protein from muscle and immune cells. Getting enough to eat may be temporarily more important than eating the "right" foods. Long-term follow up, for as long as 10 years, often is necessary to make sure that old habits don't resurface and cause malnutrition.

Most people who have ARFID will be referred to psychotherapy. Cognitive behavioral therapy is most often recommended for the condition. There are online programs for both ARFID patients and parents when it is not possible to come in to see the therapist in person.

  • Fisher MM, Rosen DS, Ornstein RM, Mammel KA, Katzman DK, Rome ES, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a "new disorder" in DSM-5. J Adolesc Health. 2014 Jul. 55 (1):49-52.
  • Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord. 2014. 2 (1):21.
  • Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord. 2014. 2 (1):21.
  • Photo courtesy of SteadyHealth

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