Avoidant/restrictive food intake disorder (ARFID) is defined by the DSM-5 as an eating or feeding disorder characterised by a persistent and disturbed pattern of feeding or eating that leads to a failure to meet nutritional/energy needs.

Diagnosis is associated with at least one of the following:

(1) Significant weight loss (or failure to achieve weight gain/physical growth in children);

(2) Significant nutritional deficiency;

(3) Dependence on tube feeding (supplying nutrients directly to the gastrointestinal tract) or oral nutritional supplements;

(4) Marked interference on an individual’s psychosocial functioning (e.g., impacts on daily activities).

Diagnosis is made if symptoms are not better explained by a concurrent medical condition (e.g., allergies, intolerances, other medical conditions), other mental illness (including other eating disorders, such as Anorexia Nervosa), a lack of available food or a cultural practice (e.g., Ramadan). ARFID differs from picky or fussy eating, which is common in childhood and generally resolves over time (e.g., food neophobia).

The food avoidance and restriction that define ARFID can lead to medical or mental health consequences that further exacerbate food avoidance and restriction and serve to maintain the illness. ARFID is persistent, more severe, can involve the restriction of both familiar and new foods, and has significant physical and mental health consequences.

ARFID is associated with the following:

• Fear of consequences associated with eating/feeding, such as choking, a phobia of a particular foods/eating 
• Sensory sensitivity, such as avoiding fruit and vegetables, crunchy foods 
• Lack of interest in eating or food, for example forgetting to eat, not feeling hungry, lack of pleasure in eating

A person may restrict the amount or type of a particular food or avoid a particular food based on factors such as the appearance of the food (e.g., colour, size, shape), texture, smell, temperature, or food group (e.g., all vegetables after a bad experience choking on a vegetable). They may also restrict food intake due to early satiety (i.e., prematurely feels full) or due to past experiences, such as trauma associated with a food experience (e.g., choking).  

Defined by a pattern of eating that is limited in variety (e.g., avoidance of specific foods) and/or volume (e.g., restriction of amount), ARFID can cause a person to become seriously ill because their bodies aren’t getting all the nutrients they need. For example, individuals may experience medical or mental health consequences such as poor growth, diabetes, cardiovascular disease, fatigue, poor self-esteem, family mealtime conflict, peer social isolation, and difficulties with school, relationships and work. 

While ARFID is similar to anorexia nervosa in that a person restricts their food intake, the intent or reason for restricting food intake differs between the two eating disorders. People with ARFID do not restrict food to avoid weight gain/control weight or to change their body size/shape. ARFID is not associated with weight or shape concerns – weight loss or change in shape may occur as a result of poor nutritional intake, not because a person is intentionally engaging in weight control behaviours.  

Individuals of all ages and genders can have clinically significant avoidant/restrictive eating that does not always begin in early childhood. Importantly, food avoidance/restriction does not always or only lead to weight loss. Depending on food intake (type and amount) and reliance on tube feeding/oral supplements, ARFID is experienced by individuals across the weight spectrum.

Some of the more common signs and symptoms of ARFID are:

• Fear of consequences associated with eating/feeding
• Appearing to be a ‘picky eater’, is fearful of, or has a phobia of certain foods
• No evidence of being preoccupied with body shape or weight but rather experiences anxiety about the food itself
• Avoiding events where food will be served or becomes distressed when preferred foods aren’t available
• Anxiety and fear around food and/or eating
• Sensory sensitivity
• Overly sensitive to certain aspects of foods, focusing on taste, texture, smell, temperature or food group
• May feel prematurely full while eating
• Lack of interest in eating or food
• Not eating enough or skipping meals entirely
• Is not engaging in behaviours to attempt to control weight (e.g., lose weight, prevent weight gain, change body size/shape)
• Disinterested in food or forgetting to eat
• Needing to take nutritional supplements
• Malnutrition

Physical signs and effects of ARFID

• Brain – preoccupation with food, headaches, fainting, dizziness, mood swings, anxiety, depression
• Hair and skin – dry skin, brittle nails, hair loss and thin hair, bruises easily, yellow complexion, growth of thin white hair all over body (called lanugo), intolerance to cold
• Heart and blood – poor circulation, irregular or slow heartbeat, very low blood pressure, cardiac arrest, heart failure, low iron levels (anaemia)
• Intestines – constipated, diarrhoea, bloating, abdominal pain
• Hormones – irregular or absent periods, loss of libido, infertility
• Kidneys – dehydration, kidney failure
• Bones and muscles – loss of bone calcium (osteopenia), osteoporosis, muscle loss, weakness, fatigue

Tommy was a 12-year-old Caucasian boy who presented for treatment because he ate a limited diet which was contributing to significant weight loss, low self-esteem and difficulties socializing with others and attending school. 

He explained that he found it difficult to eat in front of others (e.g., at school), outside the home (e.g., socialising or at restaurants), or with his family because he was anxious that his preferred foods would not be available or that others would negatively judge his food choices. ‘I have a lot of anxiety around foods that I’m not comfortable eating, or not used to eating,’ he explained. Tommy’s diet at initial presentation consisted almost entirely of white foods (e.g., white bread, white rice, white cereals, potato, or yoghurt). His diet did not include any fruits or vegetables aside from potato and was limited in proteins. Another striking feature of Tommy’s clinical presentation was that he often waited long periods of time (up to seven hours) between eating episodes. At school, he rarely ate due to embarrassment about his limited diet, difficulty planning lunches with preferred foods, and low appetite. Even at home, his mother stated that she often needed to prompt Tommy to eat. 

*It is important to note that presentations of ARFID can differ substantially and consideration needs to be taken to diagnosis and individualised treatment. 

Yes! It is possible to recover from ARFID, even if you or your loved one has been living with the illness for many years. The path to recovery can be long and challenging, however with the right supports, recovery is achievable. Different treatment options are available for ARFID; seek help from a professional with specialised knowledge in eating disorders.

If you suspect that you or someone you know has ARFID, it is important to seek help immediately. The earlier you seek help the closer you are to recovery.

Find out how EDV can help guide and support your recovery:

• EDV Hub – helpline service providing information, navigation and general support. Open Mon – Fri, 9.30am – 4.30pm.
• Telehealth Counselling –  up to five, free 30-45 minute sessions with a trained counsellor to help you take the next step in your recovery. Whether you are just starting to seek help, are on a waitlist for treatment or are wanting to re-engage with support after relapse, EDV’s understanding Counselling team are here to support you. Carers and families are also encouraged to speak to EDV Telehealth Counsellors. 
• Telehealth Nurse – free and expert guidance with registered nurses who specialise in eating disorders. Nurses listen to your unique circumstance and help you navigate and access specialised eating disorder services. Nurses can also support clients and health professionals around medical management for eating disorders.
• Online Support Groups – peer-led groups that provide an open space to discuss what you are struggling with, reflect on current challenges and discuss coping tools. Different groups are available depending on your needs. You are welcome to attend multiple groups. 
• Peer Mentoring Program – 1:1 recovery support with an EDV mentor who has experienced and recovered from an eating disorder. The program allows for 13 mentoring sessions over a six month period.
• Carer and Family Support – carer specific services including Carer Coaching and online courses.
• LearnED eLearning platform – for self-paced education and online courses
• EDV Podcast – for lived experience perspectives and professional insights
• EDV Newsletters – for recovery support delivered directly to your inbox each month

Our friends at Eating Disorders Families Australia also run a strive ARFID support group online every 3 months.

References: 

Dovey, T. M., Aldridge, V. K., Martin, C. I., Wilken, M., & Meyer, C. (2016). Screening Avoidant/Restrictive Food Intake Disorder (ARFID) in children: Outcomes from utilitarian versus specialist psychometrics. Eating behaviors, 23, 162-167. 

Thomas, J. J., & Eddy, K. T. (2018). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: children, adolescents, and adults. Cambridge University Press.