Avoidant/Restrictive Food Intake Disorder Very Common with Neurogastroenterology Symptoms

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Avoidant/restrictive food intake disorder (ARFID) is a newer diagnosis characterized by eating disturbance that results in failure to meet nutritional needs. Unlike anorexia nervosa or bulimia nervosa, ARFID is not primarily motivated by concerns about body shape or weight. Rather, individuals with ARFID have one or more prototypic motivations for avoiding and restricting their eating:

• Heightened sensitivity to sensory characteristics—e.g., taste, texture or smell
• Lack of interest in eating—lack of hunger, forgetting to eat, early satiety or postprandial fullness
• Fear—that a negative physical symptom will result from consuming certain food types or amounts

There is substantial overlap between ARFID and disorders of gut–brain interaction (DGBI), and distinguishing between the two is important. Conventional treatment for some DGBI involves food avoidance (e.g., the FODMAP diet), whereas treatment for ARFID encourages regular eating and exposure to a variety of foods, typically under the guidance of a behavioral health provider.

Based on the results of a retrospective study, Helen Burton Murray, PhD, psychology clinical and research fellow in the Department of Medicine at Massachusetts General Hospital, Braden Kuo, MD, gastroenterologist and director of the Center for Neurointestinal Health, and colleagues recommend that patients undergoing neurogastroenterology or motility examinations be screened for ARFID. Their report appears in Clinical Gastroenterology and Hepatology.

Study Details

The study evaluated 410 consecutively referred adults (ages 18–90; 73% female) who presented for initial neurogastroenterology evaluation in 2016. Three coders reviewed the subjects' medical records through May 31, 2018, for evidence of eating disorders.

Prevalence of ARFID

ARFID symptoms were present in 23.6% of patients, of whom 6.3% had definite ARFID (met all DSM-5 criteria) and 17.3% had potential ARFID. Yet only one patient was diagnosed with ARFID by their gastroenterologist—more than 1.5 years after initial evaluation.

Type of Presentation

Researchers studied various presentations of ARFID symptoms within patients. They found the following:

• Sensory sensitivity: 0%
• Lack of interest in eating: 22%
• Fear of aversive consequences: 93%—all were fears related to gastrointestinal symptoms, most commonly nausea, bloating, generalized abdominal pain/discomfort or vomiting

There was overlap among presentations: 78% of patients presented with only the fear of aversive consequences, 7% with only lack of interest, and 14% with both.

GI Symptoms and ARFID

The likelihood of definite or probable ARFID was significantly associated with:

• Eating/weight-related complaints at presentation (e.g., low weight, weight loss, poor appetite and food aversion): OR, 5.09
• Dyspepsia, nausea or vomiting diagnosis: OR, 3.59—Gastroparesis and postprandial distress syndrome were the only diagnoses noticeably more frequent in patients with ARFID symptoms than those without
• Chronic abdominal pain diagnosis: OR, 4.72
• Lower GI diagnoses: OR, 2.04—Irritable bowel syndrome-constipation type and chronic constipation were the diagnoses more frequent in patients with vs. without ARFID

Tips for Clinicians

Screening for ARFID is particularly relevant when patients report complaints related to weight or eating (e.g., poor appetite, food aversion) or would otherwise receive diagnoses related to dyspepsia, nausea/vomiting, constipation or abdominal pain.

Most individuals in this study who had ARFID with a fear of aversive consequences probably developed ARFID symptoms while attempting to manage their GI symptoms. Patients should be counseled that food avoidance and restriction can perpetuate GI symptoms.

As this study demonstrates, an ARFID diagnosis may be warranted even if the patient has a GI diagnosis.

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