Understanding the Intersection of Gastrointestinal Disorders and Avoidant/Restrictive Food Intake Disorder (ARFID)

Understanding ARFID

Unlike other EDs such as anorexia nervosa or bulimia nervosa, ARFID is not initially driven by body shape concerns, though they can develop over time. Instead, ARFID involves restrictive eating characterized by one or more of the following:

1. Sensory sensitivity: Heightened sensitivity to sensory characteristics (eg, taste/texture/smell)               
2. Lack of interest in eating or food: Lack of hunger, forgetting to eat, early satiety, and/or postprandial fullness              
3. Fear of aversive consequences: Fear that a negative outcome will result from consuming food types or amounts (eg, vomiting, choking, abdominal pain, diarrhea, bloating, or other feared physical symptom) (Murray et al., 2020).

ARFID is manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of a) significant weight loss (or failure to achieve expected weight gain or faltering growth in children); b) significant nutritional deficiency; c) dependence on enteral feeding or oral nutritional supplements and/or d) marked interference with psychosocial functioning. Diagnosis also requires that the disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice and that, when the eating disturbance occurs in the context of another mental disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder (Substance Abuse and Mental Health Services Administration).

ARFID often goes undiagnosed, particularly in adult populations, since it requires a nuanced assessment of whether a patient’s dietary restriction goes beyond what would be necessary for symptom management. Studies have found ARFID symptoms in approximately 17-24% of patients with functional GI disorders, highlighting the need for frequent screening and tailored treatment strategies (Murray et al., 2020; Atkins et al., 2023).

The Link Between ARFID and GI Disorders

Patients with GI disorders often attempt self-directed or clinician-recommended dietary modifications, including exclusion diets, to manage symptoms. While these approaches may provide relief, they can lead to nutritional deficiencies, social isolation and symptom exacerbation if not implemented properly. Association of certain foods with symptoms or negative consequences can lead to heightened awareness of digestive sensations and create a cycle of restriction that is difficult to break (Harer, 2019). In fact, those who have been on a restrictive diet, such as low FODMAP or gluten-free, are three times more likely to develop ARFID symptoms (Atkins et al., 2023). Additional risk factors for ARFID include greater GI symptom severity and comorbid conditions, such as anxiety, depression, a history of trauma and neurodevelopmental disorders (eg. attention-deficit/hyperactivity disorder (ADHD)). 

Conversely, due to the bi-directional relationship between ARFID and GI symptoms chronic restriction may impact digestion. Undernutrition can lead to reduced activity of the gastrocolic reflex and passive muscle atrophy and may impair carbohydrate absorption. This in turn compromises digestive function, which may contribute to GI symptoms such as constipation, early satiety, nausea, bloating and gas. These GI symptoms may then further reinforce restrictive eating patterns as patients seek to gain control over symptoms through increasing dietary elimination.

Restriction may also have psychological consequences. Malnutrition reduces cognitive flexibility and can lead to rigid thinking, food rules and reluctance towards dietary expansion. And lastly, the microbiome may also play a role, as inadequate intake or malnutrition can disrupt gut microbiota, which may impact GI symptoms and mental health (Zickgraf et al., 2022). With treatment, however, both brain activity and digestive function can be restored and the cycle between dietary restriction and GI symptoms can be broken (Werlang et al., 2021). 

Screening for ARFID in GI Populations

Accurate identification of ARFID in GI populations is critical to provide ED-informed treatment and avoid over-recommendation of GI restrictive diets. Traditional ED screening tools often fail to detect ARFID, as they generally focus on body image concerns and do not account for potential restriction due to GI symptoms. However, in clinical practice two self-administered screening tools are available to assess for ARFID symptoms within GI:

• Nine-Item ARFID Screen (NIAS): a 9-item questionnaire validated to identify ARFID-associated eating behaviors (Zickgraf & Ellis, 2018).
• Fear of Food Questionnaire (FFQ): an 18-item questionnaire validated to measure fear and avoidance of food and eating driven by anxiety about GI symptoms. Higher FFQ scores correlate with visceral hypersensitivity, catastrophizing, GI symptom severity, health related quality of life, and self-reported fear-related ARFID symptoms. (Zickgraf et al., 2022).

Beyond screening tools, open-ended questions about food habits and symptom triggers can also help identify ARFID symptoms. For example, asking about a patient’s use of elimination diets or fear of eating certain foods due to physical discomfort may uncover maladaptive eating behaviors.

Treatment Considerations

Treatment for ARFID in the setting of a GI disorder should first focus on restoring nutritional adequacy, then aim to expand dietary diversity. A variety of interventions can support these goals, such as meal planning and reintroduction exercises, like food fear hierarchies, food chaining exercises and exposure therapies. Additionally, interventions that do not prescribe diet restriction can provide digestive support during rehabilitation. These include tools to manage symptoms like magnesium citrate or oxide, digestive enzymes, enteric-coated peppermint, l-glutamine, behavioral therapies and constipation aids, such as fiber supplements or fiber-rich foods. 

Given the high risk for an ED among the GI population, it is crucial to recommend dietary interventions only when clinically appropriate. For conditions that require strict dietary restrictions, such as celiac disease, work closely with patients to ensure adherence to the diet requirements while promoting dietary flexibility. Aim to help patients understand the necessities of their dietary restrictions to reduce risk that food restrictions hinder social engagement and detract from quality of life.

For patients with food sensitivities, such as FODMAP intolerances, dietary eliminations should be discontinued if they do not lead to symptom relief or meaningful improvement. If a patient remains resistant to reintroduce foods despite guidance and support, further evaluation for an ED is warranted.

Conclusion

The intersection of GI disorders and EDs, such as ARFID, underscores the importance of nuanced, interdisciplinary care to balance the need for symptom management while preventing maladaptive diet patterns and thoughts. Early identification of patients with maladaptive eating behaviors can guide selection of ED-informed treatment strategies that promote psycho-social wellbeing and digestive function. Still, despite increased recognition of EDs in the GI population, additional research is needed to develop more diagnostic tools and clinical guidelines that can better support patients and providers.

Learn more about GI conditions and ARFID in our recent free webinar, Nutritional Management of ARFID in GI Patients, where expert GI dietitian, Kate Mintz, MS, RDN, shares nutritional strategies and interventions when counseling patients at the intersection of these conditions. Watch here