Imagine a world where the sight, smell, or texture of most foods triggers intense anxiety or disgust. For individuals with avoidant/restrictive food intake disorder (ARFID), this is everyday life. Sometimes described as a “selective eating disorder,” ARFID is a complex condition that goes beyond simple picky eating.
The condition is characterized by persistent failure to meet nutritional requirements, often resulting in significant weight loss, nutritional deficiencies, and even reliance on supplements or tube feeding.
Unlike other eating disorders, ARFID is not caused by concerns about body image or a desire to lose weight. Instead, individuals with ARFID may avoid food due to sensory sensitivities, fear of choking or vomiting, or lack of interest in eating in general. This can lead to severely restricted diets, social isolation, and serious health complications.
As awareness of ARFID increases, it becomes important for both the public and healthcare professionals to understand the symptoms, challenges, and effective coping strategies for ARFID.
What causes ARFID, the 'silent eating disorder'?
It is estimated that 0.5% to 5% of children and adults have ARFID.1 It is considered a relatively new diagnosis. It was added in 2013 to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (a manual published by the American Psychiatric Association that provides standardized criteria for the classification and diagnosis of mental health disorders).2
“I like to call it the silent eating disorder because it’s so common, yet it’s the least studied, the least talked about, and the least funded at the federal research level,” says Stuart Murray, an assistant professor of psychiatry and behavioral sciences and director of the Eating Disorders Clinical Research Lab at the University of Southern California.3
The exact cause of ARFID is not fully understood, but research suggests that it is likely caused by a complex interplay of biological, psychological, and environmental factors. Biological factors may include sensory sensitivity, genetic predisposition, and neurological differences in taste or olfactory processing.
Hormone studies have shown that people with ARFID have abnormally high levels of satiety-promoting substances (such as peptide YY, cholecystokinin, and oxytocin) and low levels of hunger-stimulating hormones (such as ghrelin), which may play a role in the development or persistence of the disorder.4
Psychological factors also often play an important role.5 ARFID is frequently comorbid with anxiety disorders, autism spectrum disorders, or obsessive-compulsive tendencies. For example, a systematic review published in the European Eating Disorders Review found that anxiety disorders occur in 9% to 72% of ARFID patients, while autism affects 8% to 54.75% of ARFID patients.6
Traumatic experiences with food, such as choking, may also contribute to the development of the disorder, Jennifer Thomas, of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, explained in Psychiatric Annals:7
“One of the first patients I saw with avoidant/restrictive eating disorder (ARFID) was an 11-year-old girl who came to our hospital-based eating disorders clinic because of rapid weight loss. She had recently developed an intense fear of eating most solid foods after choking on a piece of pork while having dinner with her family. She reported that she was afraid to eat even a grain of rice, her eyes wide.
When researching her medical history, we learned from her parents that she had been a 'fussy eater' all her life (with a strong preference for simple foods, like buttered pasta) and had always had a poor appetite.
Unlike most of the patients seen in our hospital at that time, this girl was extremely distressed about losing weight and wanted to regain it. Her clinical presentation thus stood in stark contrast to most of the other patients whose eating disordered behavior was partly sustained by a persistent desire to be thin.”
Environmental factors such as difficulty feeding during infancy, parental anxiety about feeding, and limited exposure to a variety of foods during infancy may also increase the risk of ARFID.8
Additionally, certain temperamental traits, such as high sensitivity, rigidity in routines, or perfectionism, may predispose individuals to developing this disorder. It is important to note that ARFID can develop at any age and is not always associated with a specific trigger event, so each case is unique in its origin and presentation.
What are the signs and symptoms of ARFID?
This condition presents differently in each person, but there are some common signs and symptoms to watch for. The most obvious is a very restricted diet, often limited to a small number of “safe” foods. These safe foods may be of a certain color, texture, or brand. Individuals with ARFID may reject entire food groups, such as fruits, vegetables, or proteins, resulting in nutritional imbalances.
But ARFID goes beyond picky eating to serious food avoidance. “A picky eater might only eat certain foods on their plate, or they might eat very little,” Murray told CNN. “Someone with ARFID might not eat anything on their plate if there’s something they don’t like on their plate.”9
Physical symptoms of ARFID may include significant weight loss or, in children, failure to gain weight or grow as expected. Gastrointestinal problems are common, as are signs of malnutrition, such as fatigue, weakness, or hair loss. In severe cases, individuals may need nutritional supplements or even a feeding tube to maintain health.
Emotionally and behaviorally, people with ARFID often show high levels of anxiety about food and eating situations. They may avoid social events involving food, have difficulty eating in public, or experience panic attacks when presented with new or feared foods.
Unlike those with anorexia nervosa, those with ARFID do not typically express concerns about body image or weight gain. Instead, their food avoidance may stem from a fear of choking, vomiting, or experiencing other negative consequences from eating.
Living with ARFID carries health risks and social barriers
Individuals with ARFID face a number of challenges that extend far beyond mealtimes. The severely restricted diet typical of ARFID can lead to serious nutritional deficiencies, potentially leading to a number of health complications. These may include:10
|
anemia |
Your immune system is weakened. |
|
Osteoporosis |
Electrolyte imbalance |
|
low blood pressure |
Cardiac arrest |
|
Delayed puberty |
Long-term damage |
In children with ARFID, growth delays are common, and adults may experience unhealthy weight loss and muscle wasting. Deficiency of essential nutrients in the body can also affect cognitive function, causing difficulty concentrating, memory, and overall mental acuity.
Additionally, social situations are often a source of extreme anxiety for people with ARFID. Attending social gatherings or even family meals can be an incredibly stressful experience. This social isolation can lead to loneliness, depression, and low self-esteem. In the workplace, business lunches or team building events that center around food can be a barrier to career advancement.
For children and adolescents, school cafeterias and birthday parties can be particularly difficult, potentially affecting social development and peer relationships. The psychological toll of ARFID should not be underestimated. Many individuals with this disorder experience intense anxiety about food, which can spread to other areas of their lives.
The constant worry about encountering or being pressured to eat unfamiliar foods can be exhausting and overwhelming. This chronic stress can worsen existing mental health conditions or contribute to the development of new ones.
Additionally, the misunderstanding and lack of awareness surrounding ARFID can lead to feelings of frustration and isolation, as people may feel that others do not understand or take their difficulties seriously. This can create barriers to seeking help and support, which can prolong the duration and severity of the disorder. Claire Lidstrand, who lives with ARFID, told Inspire the Mind:11
“Living with ARFID can feel very isolating. Many social events revolve around food, so it’s almost impossible to avoid questions about what you eat. As a result, social anxiety often occurs with ARFID, as people become increasingly self-conscious about their eating.
It’s even harder when people around us often scrutinize our choices. People often comment on my portion size… or how my food lacks seasoning. I’m usually open to answering questions and helping people understand, but I don’t always want to discuss the details of my disability with strangers…
Eating privately is often easier than answering questions or getting feedback from others… Eating in public can be incredibly stressful, so for many, it's an act of courage.”
Natural Approach to ARFID Treatment
Treatment for ARFID typically involves a multidisciplinary approach that combines psychological interventions and nutritional support. Cognitive behavioral therapy (CBT), which helps modify behaviors, thoughts, and feelings tailored to ARFID, has shown promising results.12
This treatment helps individuals challenge and change negative thoughts and behaviors about food. Exposure therapy, a core component of CBT for ARFID,13 Gradually introduce feared or avoided foods in a controlled and supportive environment. This step-by-step approach helps individuals build confidence and reduce anxiety about eating.
Family-based treatment originally developed for anorexia nervosa has been adapted for ARFID with positive results, especially in young children.14 This approach involves the entire family in the treatment process, educates them about the disorder, and teaches them strategies to support the individual at home. Parents or caregivers play a key role in meal planning, encouragement, and creating a positive eating environment.
Additionally, occupational therapy can be particularly beneficial for people with sensory sensitivities.15 Occupational therapists can develop sensory desensitization techniques and help individuals develop strategies to cope with the textures or smells of challenging foods.
Nutritional counseling is another cornerstone of ARFID treatment. A holistic health care practitioner can work with the individual to gradually expand the diet while ensuring that nutritional needs are met.
This may include creative meal planning and food chaining.16 — Matching accepted foods with new foods that have similar properties — and recommending supplements if needed. Some people find success with mindfulness and relaxation techniques, which can help manage anxiety related to eating.
Yoga, meditation, and breathing exercises can also be valuable tools for reducing stress and developing a more positive relationship with food. Recovery from ARFID can be a long process, but these natural approaches offer hope and have helped many individuals expand their diet and improve their quality of life.
