Avoidant/Restrictive Food Intake Disorder (ARFID) is about more than "picky eating." It stems from chronic food avoidance or restriction that leads to severe weight loss and nutritional deficiency. Unlike other eating disorders, ARFID is not related to body image.
Following an ARFID diagnosis, management is similar in some ways to other eating disorders. Ideally, treatment involves a comprehensive, culturally appropriate, and person-centered approach that incorporates medical, psychiatric, psychological, and nutritional expertise. In addition to primary care and mental health clinicians, comorbidities often require collaboration with a variety of specialists.
The fairly recent diagnostic designation of ARFID means that evidence about how best to treat this complex disorder is lacking. Currently, treatment focuses on improving weight and nutritional status (including refeeding, if needed), expanding food repertoire, and addressing eating-related behaviors. Depending on the severity and level of malnutrition, treatment may be inpatient or outpatient.
While there are no FDA-approved medications for ARFID, adjunctive medications in combination with behavioral therapies (often family-based therapy or cognitive behavioral therapy) may be helpful for weight restoration and management of specific ARFID symptoms, such as eating-related social anxiety, reduced appetite, and premature satiety due to chronic malnutrition.
To establish a healthy weight goal, consider premorbid trajectories for height, weight, and body mass index, age of symptom onset, current stage of puberty, and resumption of spontaneous menstruation. An optimal treatment plan may include:
- Setting individualized goals for weekly weight gain and a target weight for those who require refeeding
- Offering eating disorder-focused psychotherapy aimed at normalizing eating and weight control behaviors, restoring weight, and addressing the psychological aspects of the disorder
- Offering eating disorder-focused family-based treatment for patients who have an involved caregiver that includes caregiver education aimed at normalizing eating and weight control behaviors and restoring weight
Lauren, the six-year-old with ARFID introduced in Part One of the series, received artificial nutrition via nasogastric tube (NGT) to ensure adequate nutrition and weight gain during hospitalization. She continued with NGT upon discharge. She was prescribed fluoxetine for generalized anxiety and referred for 24 sessions of family-based therapy (FBT) for eight months augmented with protocols targeted to emotional disorders in children and adolescents.
Together, Lauren and her mother identified three goals: (1) eat enough so that NGT is no longer needed, (2) expand food variety, and (3) take medications orally. These goals were meaningful to Lauren. She was self-conscious about returning to school with the NGT and afraid of tube-changing procedures.
Psychoeducation focused on defining ARFID as an illness, which helped reduce stigma and shame, and Lauren learned how to handle strong feelings about food and eating. A targeted system of rewards reinforced constructive behaviors -- like staying at the table, taking another bite, trying a new food, completing meals, having normalized conversations at mealtime.
Psychotherapy often focuses on a ARFID profile, based on an individual’s primary motivations for avoiding or restricting food.
- For sensory food avoidance, strategies may include behavioral approaches, repeated exposures to new foods, development of a food hierarchy to expand the person’s food repertoire, and reward-based behavior modification with anxiety management or cognitive behavioral therapy (CBT).
- CBT may also be beneficial for emotional or anxiety-based food avoidance along with providing a peaceful eating environment and anxiety management.
- Fear-based food avoidance may be addressed with psychoeducation, systematic desensitization, CBT, anxiety management (perhaps with adjunctive pharmacotherapy), and relaxation training.
- Reward-based behavior modification and lifestyle changes may be beneficial for temperament-based (just don’t feel like it) food avoidance.
- Treatment of the underlying medical condition and encouragement of adequate nutrition are paramount for medical symptom-related food avoidance. If needed, oral supplementation, enteral nutrition, antiemetics, and behavior incentives may be added to the treatment plan.
As Lauren’s case suggests, motivations for avoidance/restriction may, and often do, overlap. The complexity of ARFID requires an individualized yet integrated approach to treatment and follow-up to address the variety of clinical presentations, symptoms, and sequalae.
For Lauren, her food intake improved rather quickly. She became accustomed to routine eating and managing her emotions, and eventually the increased exposure to oral medications eliminated the need for NGT.
The long-term outcomes for ARFID are unclear. But early intervention and culturally appropriate multimodal treatment can go a long way toward successfully treating the condition and mitigating short- and long-term complications.
For handouts and information to share with your patients, see DynaMedex Patient Information on ARFID.
