By Anupama Das, MD, MPH

This blog was written for the ARFID Collaborative and featured on their website.

 Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder that is characterized by selective or restricted eating leading to inadequate nutrition.  Unlike other commonly recognized eating disorders such as anorexia nervosa, ARFID is not fueled by a desire or drive for thinness, fear of weight gain, body dysmorphia, or other body image disturbances.  It’s important to note that some common eating disorder treatment efforts, such as body image exercises, might not be applicable to people with ARFID while others, such as working through a fear food hierarchy, might be similar. Identifying treatment providers familiar with the psychological, medical, nutritional, and social impacts of ARFID, which was the most recent eating disorder diagnosis added to the DSM-V (aka the handbook for mental health diagnoses), is important for proper care and recovery support.

Factors often associated with ARFID include:

• Autism Spectrum Disorder (ASD) and/or sensory issues in which certain textures, sounds, or sensory experience result in the avoidance or consumption of certain foods.
• Medical conditions that can cause physical discomfort and pain due to eating.  Mast Cell Activation Syndrome (MCAS), Gastroesophageal Reflux Disease (GERD), Superior Mesenteric Artery Syndrome (SMAS), Median Arcuate Ligament Syndrome (MALS), Inflammatory bowel disease (IBD), food allergies, and celiac disease are just a few of the medical conditions that can generate fear/reluctance to eat to avoid pain and discomfort as negative conditioning is a very powerful type of reinforcement.  Many times, even after the medical condition has been treated, individuals are reluctant to start eating again due to fear and anxiety.
• In some cases, traumatic experiences, such as choking, associated with consuming certain types of food can lead to avoidance of these foods.

As a medical provider specializing in the care and treatment of eating disorders, I have seen many medical/physiological complications due to ARFID such as:

Overall malnutrition resulting in:

  • Failure to grow

  • Weight loss

  • Delayed puberty or falling off growth curves

  • Hypoglycemia or low blood sugar levels

  • Muscle wasting

  • Dizziness and fainting/syncope

  • Gastrointestinal issues such as early fullness, nausea, constipation, abdominal pain

  • Cold intolerance

  • Dry skin and brittle nails

  • Fine hair on body (lanugo)

  • Thinning of hair on head, dry and brittle quality of hair

  • Bone density loss which can result in fractures/osteopenia/osteoporosis

  • Hormonal irregularities including changes to the menstrual cycle

  • Fatigue 

Over time, selective restriction of certain foods or food groups can result in specific nutrient deficiencies.  Examples include: 

  • Deficiencies of fat-soluble vitamins in individuals who avoid consuming fats.  This can result in vitamin A, D, E, and K deficiency.

  • Deficiency in iron due to a reluctance/fear to eat iron-rich foods such as certain vegetables or iron-containing meats.

Although many nutritional consequences arise from deficiency of dietary intake, some individuals with ARFID exhibit complications due to excessive intake of macro and micronutrients. For example, excessive intake of fat-soluble vitamins, such as vitamins A, D, E, and K, can lead to symptoms of toxicity as these vitamins accumulate in the liver and fatty tissue over time. Supplements (if tolerated) and the use of nasogastric (NG) tubes can be helpful temporary dietary and medical supports when appropriate.

While ARFID isn’t fueled by a drive for thinness, some people do develop other restrictive eating disorders such as anorexia nervosa restricting subtype or anorexia nervosa binge-purge subtype. In these situations, an individual with ARFID often loses weight and is praised for the changes in their appearance.  This positive reinforcement can inadvertently lead to intentional weight loss and the development of other forms of eating disorders. Additionally, as an individual’s body becomes malnourished, they can develop depression, fatigue, anxiety, and/or insomnia, all of which can contribute to psychological pain and suffering. The inability to eat freely can also lead to avoidance of social situations where food is involved, resulting in social isolation.  

People with ARFID can absolutely recover and experience a life with greater food freedom and flexibility. Finding a skilled multi-disciplinary team (which often includes a dietitian, therapist, physician, and other specialists such as an occupational therapist) skilled at understanding and working with ARFID is an important step towards recovery.