Afraid to Eat -Could be “Avoidant Restrictive Food Intake Disorder”

A recent case report (JJ Thomas et al. NEJM 2017; 376: 2377-86) provides insight into something I’ve seen a lot but did not have a good label for previously: Avoidant Restrictive Food Intake Disorder (ARFID).

This report highlights an 11 year old who after a having a piece of meat briefly lodged into an orthodontic palate expander, stopped eating solid foods because she was “afraid I can’t chew it up enough to swallow it so I don’t choke.”  Even before this event, she had been a highly selective eater since infancy.  “Similar to many patients with ARFID, this patient had a long-term failure to gain weight appropriately and now had more acute weight loss.”  She did desired to gain weight and did not have any body distortion typical for anorexia nervosa.

This report provides a good list of etiologies which could trigger acute food refusal as well as conditions that could cause chronic poor weight gain.

  • For acute food refusal, etiologies included acute oromotor dysfunction, foreign body ingestion, gastrointestinal ulceration, anorexia nervosa/other psychiatric reasons (including globus hystericus).
  • For chronic failure to gain weight: chronic oromotor dysfunction (numerous neurologic causes), achalasia, inflammatory bowel disease, celiac disease, endocrine etiologies (eg. Addison’s, hyperthyroidism, type 1 diabetes mellitus), infections (eg. tuberculosis, HIV), insufficient food/abuse & neglect, stimulant use, cancers, and other chronic diseases (pulmonary, cardiac, or renal)

Definition of ARFID:

  • “The presence of avoidant or restrictive eating that results in persistent failure to meet nutritional needs; evidence of ARFID includes low weight or failure to have expected gains or growth, nutritional deficiencies, reliance on nutritional supplements or enteral feeding, psychosocial impairment, or a combination of these features. Restrictive eating may be motivated by low appetite or lack of interest in eating, sensitivities to certain sensory aspects of foods, or fear of adverse consequences of eating, such as choking or vomiting.”
  • It is noted that coexisting psychiatric conditions “appear to be common among patients with ARFID. Concurrent anxiety disorders are the most prevalent; they occur in more than 70% of patients in some clinical samples.”

Treatment of ARFID:

There is little data to guide treatment.  Treatment of coexisting psychiatric conditions is recommended and behavioral interventions to improve eating.  In this patient with a choking phobia, the treatment included a gradual stepwise progression in food textures:

  • Liquids–>Purees (eg yogurt, applesauce)–>Textured purees (eg. oatmeal, mashed potatoes) –>Soft solids (eg. rice, mac & cheese, pasta, bread, potatoes, pizza) –>Crunchy solids (eg. chips, pretzels, crackers) –>Hard-to-chew solids (eg. meats)

My take: I think being able to use this relatively new term of Avoidant Restrictive Food Intake Disorder will improve disease classification and ultimately help promote better treatments.

I thought this candy store icon was funny due to the missing tooth