ARFID In Adults & Children: Symptoms & Treatment Explained

By Amy Burkhart MD, RD

ARFID In adults is on the rise.

Do you know someone who only eats a few types of foods? Maybe they only eat white foods, fried foods, or stick to hamburgers, sandwiches, and pizza, occasionally venturing to apples or carrots. The specific preferences might vary, but the pattern remains strikingly similar.

You might think it’s just picky eating, but it could be something more: Avoidant/Restrictive Food Intake Disorder (ARFID). This disorder is increasingly being recognized in adults, especially among those with anxiety, a history of trauma, or on restrictive diets, such as individuals with celiac disease.

ARFID is one of the most common eating disorders in children, and the rates in adults are climbing. Yet, many people have never heard of it. Ignoring ARFID can seriously harm one’s health, so it’s essential to understand what it is, its symptoms, and how it can be treated. Let’s explore ARFID symptoms and treatments. Fortunately, there are ways to help.

Understanding ARFID: More Than Just Picky Eating

Known as “extreme picky eating,” ARFID (Avoidant/Restrictive Food Intake Disorder) is an eating disorder that can be as harmful to health as anorexia and bulimia.

• Rising in Adults: Traditionally thought to only occur in children, ARFID is now increasingly diagnosed in adults. This rise is partly attributed to the growing popularity of restricted diets like ketogenic, paleo, and gluten-free.
• Risk Factors: While following a restricted diet does not cause ARFID, it can increase the risk of developing the disorder. Scroll down to see additional risk factors for developing ARFID
• Health Consequences: ARFID can lead to:
  • Nutritional deficiencies
  • Decreased physical abilities
  • Poor growth
  • Weight loss
  • Long-term health consequences if untreated
• Impact on Life: ARFID can severely affect a person’s personal and professional life, leading to significant long-term issues.
• Diagnosis Challenges: One of the main challenges with ARFID is recognizing the problem. It often goes undiagnosed and is normalized because “picky eating” is common in both children and adults.
• Delayed Treatment: Due to the normalization of picky eating in childhood, treatment for ARFID is often not sought until irreversible damage to the immune system or overall health has occurred.

Recognizing ARFID early and seeking appropriate treatment is crucial to prevent severe health consequences.

Symptoms of ARFID

We all have food preferences and may avoid some foods, which is normal. However, the symptoms of ARFID are more extreme and persistent.

General Symptoms

• Refusal to Eat Specific Foods: Persistent refusal to eat certain foods due to their colors, textures, or smells.
• Avoidance of Vegetables and Fruits: Individuals with ARFID commonly avoid all vegetables, especially green ones, and fruits.
• Aversion to Liquids: Often avoid drinking water or any liquids with meals or throughout the day.
• Carbohydrate-Only Diets: Eating only carbohydrate-rich foods (like bread or pasta) over a long period can lead to protein deficiency and affect brain development and growth.
• Fear-Based Refusal: Refusal to eat due to fear of becoming sick or choking on food.
• Lack of Obsession with Body Image: Unlike other eating disorders, ARFID is not driven by concerns about body shape or weight.
• Disinterest in Food: A general disinterest or avoidance of various foods.

Physical Symptoms

• Nutritional Deficiencies: Due to a limited diet, individuals may suffer from various nutritional deficiencies.
• Decreased Physical Abilities: Lack of proper nutrition can lead to reduced physical capabilities.
• Poor Growth: Especially in children, ARFID can result in stunted growth.
• Weight Loss: Significant weight loss can occur due to insufficient calorie intake.\
• Decreased appetite
• Low iron
• Dizzy or lightheaded
• Fatigue
• Cold hands and feet
• Difficulty concentrating, foggy thinking
• Frequently sick, poor immune system
• Trouble concentrating
• Hair loss
• Dry skin
• Changes in menstrual cycles/periods
• Stomach pains
• Feeling cold all the time
• General weakness

Mental symptoms

• Fear of choking or vomiting
• Not wanting to eat with others
• Bunding up to stay warm when others are not
• Anxiety around food
• Mealtimes become a time of stress and conflict around food

How common is ARFID?

Current estimates are that 9% of adults in eating disorders programs have ARFID

• The number of adults is currently unknown but believed to be much higher than the 9% enrolled in eating disorders programs
• Up to 14% of children admitted to the hospital for an eating disorder
• Up to 22 % of children in outpatient eating disorder programs have now been diagnosed with ARFID.
• It seems to affect boys more often than girls. More studies are needed on these numbers.

When someone with ARFID is forced to eat unwanted food, they may refuse the food, vomit, or be unable to eat it without experiencing a choking feeling! Does this “picky eater” sound like you or someone you know?! If so, consider ARFID.

It occurs more often in people with previous food-related issues.

• Picky eating in childhood is one of the primary risk factors for ARFID. The habits we develop in childhood often stick with us unless something or someone intervenes. However, “picky eating” in childhood does not mean the child will develop ARFID – and forcing a child to eat disliked foods not only can be traumatic for the child and make the child even more resistant.
• ADHD or autism –a major risk factor
• People who follow restrictive diets such as Paleo, Keto, Gluten-free etc.
• Celiac Disease increases the risk
• Having another eating disorder -a major risk factor
• A prior choking episode,
• Dislike of certain textures
• Prior surgery, such as oral surgery, followed by painful eating.
• Post-Traumatic Stress Disorder (PTSD) is often linked to ARFID development, so childhood trauma can increase the likelihood of developing ARFID.
• Severely “picky-eaters” of elementary or high school age are more likely to develop ARFID than their counterparts who are not such “picky-eaters.”
• Children and adults living with Obsessive-Compulsive Disorder (OCD) are more likely to develop ARFID.

Aversions to a specific food (or group of foods) most often occur due to a bad experience with that food. Most people try to avoid repeating an unpleasant experience. The problem in ARFID is that the unpleasant experience may be something imagined (rather than ever occurring) but still result in avoidance.

The following are the potential indications of ARFID  from the National Eating Disorders Association.

Criteria for Diagnosing ARFID

Eating or Feeding Disturbance

• Lack of Interest in Eating or Food: An apparent lack of interest in eating or food.
• Sensory-Based Avoidance: Avoidance based on the sensory characteristics of food (e.g., color, texture, smell).
• Fear of Aversive Consequences: Concern about negative consequences of eating, such as choking or vomiting.

Failure to Meet Nutritional/Energy Needs

• Significant Weight Loss: Noticeable and unintended weight loss or slow growth in children.
• Nutritional Deficiency: Significant nutritional deficiencies due to limited food intake.
• Dependence on Supplements: Reliance on enteral feeding or oral nutritional supplements to meet dietary needs.
• Psychosocial Interference: Marked interference with daily functioning, impacting social, educational, or occupational aspects of life.

Exclusions

• Not Due to Lack of Food or Cultural Practices: The disturbance is not explained by a lack of available food or cultural/religious dietary practices.
• Not During Other Eating Disorders: The eating disturbance does not occur exclusively during anorexia nervosa or bulimia nervosa and does not involve a preoccupation with body weight or shape.
• Not Attributable to Medical Conditions: The disturbance is not better explained by a medical condition or another mental disorder. ARFID can be diagnosed if the eating issues exceed typical restrictions associated with another condition.

Patients with ARFID are not trying to lose weight.

People with ARFID may lose weight, but this is not their intention. A desire for weight loss is not the reason they are avoiding food or losing weight. If they are limiting foods to lose weight, this typically eliminates the diagnosis of ARFID.

More adults are following restricted diets.

ARFID is being seen more frequently in adults. This is thought to be related to the increase in the number of adults following restricted diets, many of which are being used to treat underlying symptoms. Adults may have a small number of foods they will eat, often less than 20. They may also refuse new foods and/or have aversions to particular foods due to texture or sensory issues.

Picky eating in adults initially started for weight loss may put someone at an increased risk of developing ARFID. ARFID in adults is also correlated with higher rates of depression and anxiety, including OCD, obsessive-compulsive disorder

What people with ARFID say helps them

A recent survey of individuals with ARFID revealed that nearly 40% believed associating food with positive emotional experiences was crucial for their treatment. Examples of this approach include:

• Teaching cultural or nutritional lessons about different foods
• Providing alternative “safe” foods
• Teaching food preparation skills
• Assisting in food preparation

Flexibility in the approach to food, including presenting foods from specific food groups, was also important. Additionally, providing structure around eating and clearly defining expectations were helpful strategies. Importantly, encouraging individuals to try new foods was more effective than forcing them to do so.

Treatment for ARFID depends upon age.

• Family-based treatment, primarily for children and teens. Parents need to understand how to help.
• Food exposure therapy to decrease anxiety around certain foods.
• Mental visualization, writing, and talking about feared foods.
• Cognitive-Behavioral Treatment (CBT) – a type of counseling approach. This gives patients the tools needed to cope and manage their thoughts.
• Medication (if needed)– focused on reducing anxiety about food intake.
• Hospitalization and tube feeding – only in severe cases where ARFID has led to severe malnutrition.

Cognitive Behavioral Therapy (CBT) is the most widely used ARFID treatment in teenagers and adults.

• Desensitization to the food causing fear. In the case of irrational fear about a specific food item (based on color, texture, or whatever), desensitizing by exposure to small amounts increases acceptance of the food over time.
• Relaxation techniques are also employed in CBT (which can be practicing deep breathing before consuming food that produces anxiety).
• An individual treatment plan is made for each person experiencing ARFID symptoms. A “picky-eating” child may benefit from ARFID treatment even if not yet determined to have full-blown ARFID.
• Preventing worsening symptoms in a younger child may enable that child to avoid developing more severe ARFID symptoms later. The more “habits” become entrenched, the harder they are to change!
• Dietary management and meal planning by a trained dietitian are recommended. It is best to work with a dietitian familiar with ARIFD.
• During treatment, nutrition needs to be maintained to prevent related health disorders from developing. Vitamin and mineral supplements are not enough to fully compensate for the problem.
• Specific vitamins and mineral pills may be prescribed by a doctor during treatment to prevent a disorder linked to a nutritional deficiency. If vitamin levels are low, they need to be treated immediately as something such as iron deficiency can decrease appetite and make food reintroduction more difficult.

If you suspect that you, your child, or someone else you love has ARFID, talk to your doctor or a mental health professional as soon as possible.

The faster treatment is started, the more likely it will be effective and prevent other health disorders, mental or physical.

Think about how difficult it is to change a bad habit that you have had over numerous years. You really are doing yourself (or your loved one) with symptoms of ARFID a big favor by dealing with this now rather than later! You can also contact an eating disorders center near you for more information and local contacts.

Additional resources are listed here:

National Eating Disorders Organization

ARFID Therapists

Eating Disorder Dietitians  -enter your zip code and then select specialty “eating disorder.”

Academy of Nutrition And Dietetics (eating disorders information)

• Take ARFID seriously and seek help.
• ARFID is on the rise in adults
• ARFID is often associated with anxiety and obsessive-compulsive disorder
• ARFID is more than just “picky eating;” children do not grow out of it. Left untreated, they may become malnourished
• The true prevalence of ARFID is still being studied, but it may affect as many as 5 percent of children.
• It appears to be more common in boys than girls; this is under investigation.
• The majority of pediatricians are unfamiliar with the diagnosis of ARFID
• Untreated ARFID can lead to vitamin and mineral deficiencies that can be harmful to overall health.
• Untreated ARFID can result in chronic physical and mental health problems affecting long-term well-being.
• A person can have ARFID without having any other type of eating disorder (such as anorexia or binge-eating).
• Untreated ARFID can lead to disability and/or death.