‘Fussy Eating’ or Avoidant Restrictive Food Intake Disorder?

‘Fussy Eating’ or Avoidant Restrictive Food Intake Disorder?

All of us recognise ‘fussy eating’, either in ourselves, family members or friendships. We’ve often heard of the child that refuses to eat any vegetables, sauces or will only have the same limited number of foods. This can be a normal part of development for some children, however when do we start to worry as parents and when might we need help?

Avoidant restrictive food intake disorder (ARFID) is an eating disorder that goes beyond ‘picky eating’ and is recognised in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). We may recognise common eating disorders such as Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder, and although there are some commonalities such as restriction of food intake, those with ARFID do not have the same body image disturbance or fear of weight gain. 

ARFID is characterised by a feeding or eating disturbance due to a lack of interest in food, sensory avoidance, or concern about adverse consequences such as choking or vomiting. This results in either weight loss or failure to thrive, significant nutritional deficiencies or dependence on supplements, and interference with psychological or social functioning. 

ARFID is also commonly seen in young people with Autism Spectrum Disorder (ASD), due to a sensory avoidance of food ie difficulties with texture, smell or taste. Often those with ASD prefer ‘beige’ foods such as plain rice, pasta or potatoes.

A recent systematic review 1  of patients with both ARFID and ASD, found that almost 70% of those with ARFID had scurvy (vitamin C deficiency), while 17% had eye disorders as a result of vitamin A deficiency. Vitamin D, B12, and thiamine deficiencies were also reported.

The condition gained a lot of recognition in the UK in 2019 after a case of a young boy with ARFID was reported. He suffered irreversible sight and hearing problems secondary to nutritional deficiencies and difficulties in tolerating the texture of foods; other than fries, chips and white bread. Although this is a rare case, it highlights the importance of seeking support early and recognising the difficulties you or your child may be having as more than an issue of preference. 

Most children who are ‘picky eaters’ will grow out of this by the age of 4-6yrs. Despite being ‘picky’, it does not usually affect their weight or result in deficiencies. ARFID however, can persist and cause difficulties in adulthood. Parents may recognise this if their child shows a lot of distress around eating, expresses worries about something bad happening or avoids food because of how it ‘feels or smells’.

ARFID can affect a persons ability to manage social situations, may result in bullying at school or avoidance of social activities due to very restrictive eating. Given the effect it can have on weight loss and deficiencies of essential vitamins and minerals, ARFID can also affect psychological wellbeing by putting those affected in a ‘starved state’. Imagine the effects of being ‘Hangry’; low mood, irritability, anxiety; now imagine feeling this way most days or having heightened anxiety and stress around mealtimes.

So, what steps can you take for yourself or a loved one with the difficulties described, if you recognise it is more than simply ‘picky eating?’ 

The first step is to see a general family Dr to assess growth, weight, and any medical problems or deficiencies. This would usually involve blood tests and a physical examination.

Secondly, seek professional support from an Eating Disorder specialist team who will be able to assess whether the difficulties are related to an underlying ARFID and explore individual reasons for development of the difficulties or maintaining factors. A multi-disciplinary team which includes a dietician, psychologist and family Dr, is essential in treating ARFID safely and holistically. 

Treatment for ARFID includes cognitive behavioural therapy and exposure techniques to help support you as an individual or as a family. Often, as the individual with the difficulty may be a young child, specialists will work closely with parents, supporting them to help make changes within the child. Your psychologist will help you to challenge rigid beliefs about eating, manage fear or anxiety, support you in exposure to different foods and work through any maintaining factors which are contributing to the difficulties. They will also support you as a family to reduce the distress and social impact related to ARFID.

Occasionally, those with ARFID may also have other concurrent mental health difficulties such as depression, anxiety, obsessive-compulsive disorder or autism, Your psychologist or psychiatrist can also help you to manage these difficulties and support treatment of these conditions. 

 

  1. J Acad Nutr Diet 2021 Mar;121(3):467-492. Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series. Summer Yule 1Jillian Wanik 2Elizabeth M Holm 3 et al.

Written by: Dr Teizeem Dhanji

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