Study helps doctors recognize risk factors, symptoms of underdiagnosed food avoidance/restriction disorder

 BOSTON – Children often avoid certain foods and most parents don’t think too much of it, dismissing their little ones as “picky eaters” who will grow out of the phase. But the idea of adults avoiding or restricting their diets is less familiar to most people and can be a serious problem warranting treatment. A paper published in Clinical Gastroenterology and Hepatology helps doctors to recognize the symptoms and risk factors for avoidant/restrictive food intake disorder (ARFID) in adults, which was added to the DSM-5 in 2013, so patients can be properly diagnosed and get help.

“ARFID can really interfere with people’s lives,” says Helen B. Murray, MS, a clinical and investigator in MGH’s Eating Disorders Clinical and Research Program and the paper’s first author. “It can make it hard for them to function at school or work and with family and friends. Patients may avoid social interactions involving food or spend a lot of time, energy and effort thinking about their food choices, often causing problems with the family or spouse when they can’t eat things the rest of the family does.”

It can also have serious medical consequences, Murray maintains, like significant weight loss and nutritional deficiencies, sometimes leading to dependence on nutritional supplements or even tube feeding.

The good news is there is effective, exposure-based treatment for ARFID; the bad news is that “many gastroenterologists are still not aware of this diagnosis,” Murray says. Of the 97 gastroenterology patients identified through the retrospective chart review as having ARFID symptoms, only one was correctly diagnosed during the 18 months after initial presentation. “The study findings are important because they increase the awareness of ARFID and gives doctors specific presentations and diagnoses that indicate a need to screen patients for ARFID. If they’re able to detect it, the patients can get treatment faster.”

Though adults with ARFID may have sensory sensitivity to foods, avoiding certain smells, tastes, or textures, or simply lack interest in eating, the current study showed that among patients presenting to gastroenterology providers, avoiding foods or restricting eating because of “fear of aversive consequences” like vomiting, nausea, abdominal pain was the most common ARFID presentation.

“Almost 93 percent of the patients we identified as having ARFID symptoms cited fear of gastrointestinal distress as motivation for their avoidant or restrictive eating,” says Murray.

A subset of individuals with gastrointestinal conditions may be at greater risk for developing ARFID — particularly individuals who meet criteria for disorders of gut-brain interaction (DGBI), the new name for functional gastrointestinal disorders. For example, some individuals who develop a DGBI after an infection may be at risk for developing ARFID.

“The brain may have learned — say, during a bout with flu or a C. diff infection — that if I eat x food I’m going to get nauseous, and then even after the infection is gone, the brain may send signals to the gut to still produce nausea in response to food,” says Murray. “If the person starts avoiding particular foods or decreasing their intake because of the nausea, this further reinforces what the brain and gut have learned — to continue producing nausea. So there are both psychological and physiological components to it.”

The gastroenterology patients most likely to have ARFID were those who “came in saying they had an eating or weight-related complaint or received diagnoses related to symptoms of nausea, vomiting, severe fullness, or abdominal pain,” says Murray. “Those are red flags that you probably want to screen for ARFID.”

The study’s co-authors are Abbey P. Bailey, BA, Casey J. Silvernale, BA, Kyle Staller, MD, MPH, and Braden Kuo, MD, of the Center for Neurointestinal Health at MGH; and Ani C. Keshishian, BA, Kamryn T. Eddy, PhD, and Jennifer J. Thomas, PhD, of the Eating Disorders Clinical and Research Program at MGH.

About the Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $1 billion and comprises more than 8,500 researchers working across more than 30 institutes, centers and departments. In August 2019 the MGH was once again named #2 in the nation by U.S. News & World Report in its list of "America’s Best Hospitals."