Avoidant/restrictive food intake disorder: Systematic review and meta-analysis demonstrating the impact of study quality on prevalence rates.

OBJECTIVES: The prevalence of Avoidant/Restrictive Food Intake Disorder (ARFID) is unclear. This paper is the first to present meta-analysis based estimates of the prevalence of ARFID, and to assess the impact of the quality of the research on these estimates. DESIGN: A pre-registered (Prospero: CRD42023487621) systematic review and meta-analysis. METHODS: PubMed, PsychInfo, Web of Science and CINAHL were searched (final date of retrieval 30th July 2024) for peer reviewed papers published between 2013 and 2024. Random-effects and quality effects meta-analyses were used to compute and compare prevalence estimates and to evaluate the impact of study quality on prevalence rates. Subgroups were also considered (gender, age group, clinical status). Loney et al.'s (1998) Critical Appraisal of the Health Research Literature: Prevalence or Incidence of a Health Problem scale was used to assign each study a quality score across three categories - methodological validity (six points); interpretation of results (one point); and applicability of the results (one point). RESULTS: Twenty-six studies were identified (n = 122,861). Meta-analysis using random-effects indicated a prevalence of 11.14 % (95 % CI 8.16-14.5 %), whereas quality effects prevalence was 4.51 % (95 % CI 0.7-10.68 %). Similar contrasts were evident among subgroups. CONCLUSIONS: Even taking the more conservative estimate of 4.51 %, this review demonstrates that ARFID is a common disorder, meriting further research and clinical and service developments. Future research needs to be more methodologically robust (larger samples; standardised diagnostic measures; clearer data presentation).

Associations between avoidant/restrictive food intake disorder profiles and trauma exposure in veteran men and women.

OBJECTIVE: Trauma exposure, particularly interpersonal trauma, is prevalent among individuals with eating disorders (EDs), and trauma exposure and the subsequent development of posttraumatic stress disorder have been associated with poorer outcomes for ED treatment. To our knowledge, there are no published investigations of trauma exposure among individuals with avoidant/restrictive food intake disorder (ARFID), a new diagnosis introduced by the Diagnostic and Statistical Manual of Mental Disorders-5. We investigated associations between trauma exposure and ARFID profiles in a sample of U.S. military veteran men and women. METHOD: Participants in this cross-sectional study included 1494 veterans randomly selected from the population of post-9/11 veterans who had separated from military service within the previous 18 months. They completed a survey assessing EDs, including the Nine Item ARFID Screen and trauma exposure. RESULTS: Results revealed that 9.8% of the sample exceeded cutoffs for any ARFID profile, with the picky eating profile being the most common. Trauma exposure was prevalent among participants who exceeded cutoffs for ARFID, particularly the picky eating profile. DISCUSSION: Findings highlight the importance of addressing EDs, including ARFID, in veterans. It will be important to examine the extent to which trauma and trauma-related disorders impact treatment outcomes for individuals with ARFID.

Food Neophobia and Avoidant/Restrictive Food Intake among Adults and Related Factors.

Avoidant/restrictive food intake disorder (ARFID) includes age-inappropriate feeding behaviors in eating patterns, including food neophobia, defined as refusal or reluctance to eat new or unknown foods. This study aimed to assess the prevalence of ARFID and food neophobia among adults and determine the related characteristics of these risks. The study used an anonymous survey questionnaire consisting of three parts as the research tool. The first part of the questionnaire was a metric and concerned socio-demographic data. The Food Neophobia Scale (FNS) and the Nine-Item Avoidance/Restrictive Food Disorder Screen Questionnaire (NIAS) were used to evaluate the eating disorders. The survey included 309 people (60.2% women, 39.8% men) aged 18-77 years. NIAS results indicated that 15.2% of the subjects showed food selectivity, and 11.0% had food anxiety. In the FNS assessment, 42.4% had a low risk of food neophobia, 38.2% a medium risk, and 19.4% a high risk. A higher risk of food neophobia correlated with higher NIAS scores, indicating a higher risk of ARFID (p = 0.00231). The NIAS score increased with the risk of food neophobia (p = 0.000). Respondents at low risk of neophobia were most likely to avoid several products (83.97%), while in the high-risk group, 56.67% did not want to eat a favorite food enriched with a new ingredient. A higher risk of neophobia was correlated with more food avoidance and adverse reactions to new foods (p = 0.000). A higher risk of food neophobia is strongly correlated with a higher risk of ARFID. Although demographics did not significantly impact NIAS results, some trends were noted, such as higher scores among older and underweight people. Those with a higher risk of food neophobia show more food avoidance and a greater reluctance to experiment with new ingredients. Public education should emphasize that eating disorders affect both sexes equally, with tailored interventions for high-risk groups such as the elderly, rural populations, and those with lower education. Health policies should promote access to nutrition education, psychological support, and diverse food options, while further research is needed to improve targeted interventions.

Pilot Case Series Studying a Psychoeducational and Motivational Treatment for Children With Low-Weight Avoidant Restrictive Food Intake Disorder.

OBJECTIVE: Research on treatments for children with avoidant restrictive food intake disorder (ARFID) is needed. This pilot case series describes outcome data for 20 children ages 6-12 years old with a diagnosis of ARFID and who are low-weight. METHOD: Participants were recruited nationwide as part of an ongoing randomized clinical trial. All participants in this study received a 14-session psychoeducational and motivational treatment (PMT) protocol. Parents completed measures of ARFID severity (the Pica, ARFID, Rumination Disorder Interview) and parental self-efficacy (Parents vs. ARFID scale). Height and weight were self-reported by parents and percent of estimated body weight (%EBW) was calculated. Assessments occurred at baseline, 1-month within treatment, 2-months within treatment, end-of-treatment (EOT), and 6-month follow-up. RESULTS: Twenty children (10.34 ± 1.76 years; 85% Non-Hispanic; 75% White; 70% female; 84.16 ± 4.66% EBW) with low-weight ARFID and their parents received PMT-ARFID with a clinician specializing in eating disorders. By EOT, PARDI severity scores decreased (large effect size) parental self-efficacy increased (medium effect size), but %EBW remained unchanged. DISCUSSION: Additional research evaluating PMT in adequately powered clinical trials for youth with ARFID is needed.

Investigating the utility of the AQ-10 in children and adolescents assessed in an outpatient ARFID clinic.

The high co-occurrence of autism and eating disorders is well established, including for those with Avoidant Restrictive Food Intake Disorder (ARFID). It is therefore important to consider autism and identify possible autism when people present to eating disorder services to ascertain whether further assessment is indicated, to support clinical formulation and to make appropriate adaptations during interventions. This paper explores the utility of a validated autism screening measure, the AQ-10, in a population of children and adolescents who presented to an outpatient eating disorders clinic for an assessment of possible ARFID. Over 19 months, 335 young people were assessed and 246 families with children aged between 4 and 17 years completed one of three versions of the AQ-10 (Child, Adolescent, and Adult), as part of a battery of routinely administered pre-assessment questionnaires. Results indicated that 80.2% (n = 69) of those with an existing autism diagnosis scored above clinical threshold of ≥6 (M = 7.2, SD = 1.9), 43.9% (n = 43) of those queried to be autistic scored above clinical threshold (M = 5.2, SD = 2.5), and 6.5% (n = 4) of non-autistic individuals scored above clinical threshold (M = 2.8, SD = 1.8). Additionally, the AQ-10 satisfactorily discriminated between those with a known autism diagnosis and those who are not autistic across all age groups and sex. We conclude that the AQ-10, alongside a comprehensive clinical assessment and clinical judgment, is a useful screening tool that can support clinicians to identify appropriate onward referrals for autism assessments, aid clinical formulation, and consider appropriate adaptations and reasonable adjustments during ARFID interventions.

Achieved Weight Gain and Return to Work After Intervention With Traditional Japanese Acupuncture for Avoidant Restrictive Food Intake Disorder: A Case Report.

Avoidant restrictive food intake disorder (ARFID) is newly established as a category of eating disorder (ED). Acupuncture is one treatment option for ED. However, no cases of acupuncture treatment of ARFID have been reported. A 28-year-old female presented with reduced food intake and weight, abdominal bloating, abnormal sense of taste, and tongue pain. Her body weight (BW) had been around 50 kg until four years previously. Three years before, her symptoms occurred, and her BW decreased to 36.5 kg after experiencing excessive mental stress at her workplace. She was diagnosed with ARFID by a psychosomatic physician and tended to refuse her prescribed antipsychotic drugs. She was treated weekly with the Hokushin-kai style, a traditional Japanese acupuncture, and the moxibustion method. After one month, the patient felt somewhat better and returned to work once a week for the first time in two years. Four months later, her BW started to increase. After 10 months, her BW had increased to 48 kg. Her acupuncture treatment continues. This case suggests acupuncture as an optional treatment for ARFID. Further studies, such as a combination of medications and acupuncture, would be desirable.

Avoidant/Restrictive Food Intake Disorder: Review and Recent Advances.

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder recently codified in DSM-5 that affects individuals of all ages. A proliferation of ARFID research has emerged over the years, and this review provides a brief overview of the current understanding of ARFID epidemiology, symptoms, comorbid conditions, assessment, and treatment. The review highlights recent research updates regarding ARFID among adults, putative neurobiological mechanisms underlying ARFID, and new treatment trials. Findings from this review demonstrate that ARFID is as prevalent as other eating disorders, even among adults, and is associated with significant medical and psychiatric comorbid conditions. New, promising treatments for children, adolescents, and adults are in the early stages of development. Several assessments are now available to aid in the screening and diagnosis of ARFID and have demonstrated cross-cultural validity. Areas for future research and clinical guidance, including unresolved questions regarding ARFID categorization and differential diagnosis, are discussed.

Challenges of parenting children born before 24 weeks of gestation.

AIM: To assess experience of care, well-being of parents and children's development in a cohort of extremely premature infants born <24 weeks of gestation in Sweden from 2007 to 2018. METHODS: A survey based on multiple questionnaires answered by 124/349 (35.5%) parents. RESULTS: The median age of parents and children was 43 and 9 years, respectively; 74.2% were mothers. Parents expressed high healthcare satisfaction. Following discharge from neonatal care, the satisfaction with the infant's treatment, support from personnel and being respected as a parent significantly declined but remained high. The criteria for suspected developmental deviation according to the screening test early symptomatic syndromes eliciting neurodevelopmental clinical examinations-questionnaire was fulfilled by 84.3%, 55.6% had suspected avoidant restrictive food intake disorder and 47.9% had visual perception problems. Parents experienced severe fatigue (48.6%) despite strong social support and family self-efficacy. Economic support was provided to 30.6%, and 37.9% of children were enrolled in habilitation services. CONCLUSION: This study highlighted the substantial challenges faced by parents of infants born before 24 weeks of gestation, including decreased satisfaction post-discharge, fatigue and concerns about children's well-being. The findings underscore the need for comprehensive family-centred support and long-term multi-professional follow-up centres.

Psychometric properties of the nine-item avoidant/restrictive food intake disorder screen (NIAS) in Turkish adolescents.

BACKGROUND: This study evaluates the psychometric properties of the Turkish version of the Nine-Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) in a population of Turkish adolescents. METHOD: The NIAS, designed to screen for ARFID symptoms, including picky eating, fear-related eating behaviors, and low appetite, was administered to secondary school students between 13 and 18 ages in Mugla, Turkiye. RESULTS: Based on a sample of 268 adolescents, the NIAS's reliability and validity in this demographic are supported. The research utilized confirmatory factor analysis to verify its three-factor structure and various reliability tests, including Cronbach's alpha and test-retest reliability, confirming the scale's internal consistency and temporal stability. The descriptive analysis highlighted significant differences in NIAS scores across BMI categories, with underweight adolescents scoring higher, suggesting a potential link between ARFID symptoms and lower body weight. Criterion validity was supported by significant correlations between NIAS subscales and measures of anxiety, depression, and eating behaviors, indicating the scale's effectiveness in reflecting relevant psychopathological features. CONCLUSION: Overall, the study establishes the Turkish NIAS as a useful tool for identifying ARFID in Turkish adolescents, aiding early detection and intervention in this at-risk age group. Further research is recommended to explore the scale's utility across different clinical settings and refine its diagnostic accuracy, enhancing our understanding of ARFID's impact on youth mental health and nutritional status.

Cross-culturally reliable tools for assessing symptoms of Avoidant/Restrictive Food Intake Disorder (ARFID) in young people are crucial, especially during adolescence, a critical period for the emergence of various eating and feeding disorders. The Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) is a brief and practical instrument designed to assess and rate symptoms across three phenotypes associated with ARFID: 'picky eating,' 'fear,' and 'appetite,' which can lead to restricted food volume or variety. This study, focusing on a sample of Turkish adolescents, validates the reliability and accuracy of the NIAS in this particular demographic. The findings offer a foundational understanding of the ARFID profile among Turkish adolescents. The psychometric robustness of the NIAS in self-reporting among adolescents is demonstrated by significant correlations between its subscales and other measures of anxiety, depression, and eating behaviors, indicating that the scale effectively captures related psychopathological traits.

Xeropthalmia and optic neuropathy secondary to ARFID: a case report.

BACKGROUND: Patients with avoidant/restrictive food intake disorder (ARFID) commonly present with loss of weight or faltering growth in the setting of poor nutrition. However, patients with ARFID can present with micronutrient deficiencies without weight loss. In patients with ARFID, clinicians should be vigilant for micronutrient deficiencies and their presentations. CASE PRESENTATION: We report a unique case of ARFID in a twelve-year-old girl, who developed micronutrient deficiencies and presented with acute visual loss with a preceding history of impaired night vision. Ophthalmic examination revealed xerophthalmia and bilateral optic neuropathy. Investigations showed severe Vitamin A and folate deficiencies which accounted for her clinical findings. In addition, she was also found to have low Vitamin B12, copper, and Vitamin D levels. She had a history of selective eating from a young age with a diet consisting largely of carbohydrates, with no regular intake of meat, dairy, fruit and vegetables. This was not driven by weight or body image concerns. The patient's symptoms improved significantly with appropriate vitamin replacement and continued multidisciplinary care. CONCLUSIONS: This report describes a patient with ARFID presenting with visual complaints. In this case, the selective eating behaviours resulted in xeropthalmia and optic neuropathy. Micronutrient deficiencies are uncommon in developed countries. When these deficiencies are suspected, eating disorders, such as ARFID, should be considered. Similarly, clinicians caring for patients with restrictive eating disorders including ARFID should be familiar with the clinical presentations of various micronutrient deficiencies and consider evaluation and treatment for micronutrient deficiencies when clinically indicated.

Assessing growth in children and adolescents with Avoidant/Restrictive Food Intake Disorder.

BACKGROUND: Although growth delays and disruption are a well described medical complication of restrictive eating disorders in children and young adolescents, this complication has received less attention in patients with Avoidant/Restrictive Food Intake Disorder (ARFID). Patients with ARFID have challenges with adequacy of food volume and variety that are not related to body image but are instead related to lack of interest in eating, sensory concerns, and/or fears of aversive consequences. Because onset of ARFID is commonly before puberty, concerns regarding growth adequacy may present an additional treatment challenge and a unique opportunity for support. REVIEW: Child and adolescent patients with other restrictive eating disorders are at risk of irreversible deleterious impact on growth and development, particularly when onset is before or around puberty. Although faltering growth is a defining feature of ARFID, less attention has been paid to methods for examining growth concerns in young patients with ARFID and training providers to assess growth adequacy when prepubertal and peripubertal patients present with this diagnosis. Providers working with patients under 18 years of age with eating disorders will benefit from the tools discussed in this narrative review to adequately assess growth and development against genetic potential, recognize alterations in growth that are a result of nutritional deficiencies, and support and maximize catch-up growth and development when it has been impaired. CONCLUSION: Established pediatric growth monitoring tools and techniques to assess adequacy of growth can be applied to child and adolescent patients presenting with ARFID. These tools can improve long term outcomes in linear height for these patients and allow for monitoring during and after treatment until growth and development is complete. Medical providers caring for patients presenting with ARFID will need to establish best practices for assessing and monitoring growth.

Trajectory of ghrelin and PYY around a test meal in males and females with avoidant/restrictive food intake disorder versus healthy controls.

Disruptions in appetite-regulating hormones may contribute to the development and/or maintenance of avoidant/restrictive food intake disorder (ARFID). No study has previously assessed fasting levels of orexigenic ghrelin or anorexigenic peptide YY (PYY), nor their trajectory in response to food intake among youth with ARFID across the weight spectrum. We measured fasting and postprandial (30, 60, 120 minutes post-meal) levels of ghrelin and PYY among 127 males and females with full and subthreshold ARFID (n = 95) and healthy controls (HC; n = 32). We used latent growth curve analyses to examine differences in the trajectories of ghrelin and PYY between ARFID and HC. Fasting levels of ghrelin did not differ in ARFID compared to HC. Among ARFID, ghrelin levels declined more gradually than among HC in the first hour post meal (p =.005), but continued to decline between 60 and 120 minutes post meal, whereas HC plateaued (p =.005). Fasting and PYY trajectory did not differ by group. Findings did not change after adjusting for BMI percentile (M(SD)ARFID = 37(35); M(SD)HC = 53(26); p =.006) or calories consumed during the test meal (M(SD)ARFID = 294(118); M(SD)HC = 384 (48); p <.001). These data highlight a distinct trajectory of ghrelin following a test meal in youth with ARFID. Future research should examine ghrelin dysfunction as an etiological or maintenance factor of ARFID.

Variation in care for inpatients with avoidant restrictive food intake disorder leads to development of a novel inpatient clinical pathway to standardize care.

INTRODUCTION: There is limited evidence to guide management of patients with avoidant restrictive food intake disorder (ARFID) admitted for medical stabilization. We describe variations in inpatient care which led to the development of a multidisciplinary inpatient clinical pathway (ICP) to provide standardized management and examine differences after the ICP was implemented. METHODS: A retrospective review of patients with ARFID admitted to Adolescent Medicine, Gastroenterology, and General Pediatrics at a single academic center was conducted. We compare hospital utilization and use of consulting services during the pre-ICP (2015-2017) and post-ICP (2018-2020) periods. RESULTS: 110 patients were admitted with ARFID (n = 57 pre- vs. n = 53 post-ICP). Most presented with moderate/severe malnutrition (63% pre vs. 81% post; p = 0.11) and co-morbid anxiety and/or depression (74% pre vs. 92% post; p = 0.01). There was some variation in use of enteral tube feeding by service in both periods (p = 0.76 and p = 0.38, respectively), although overall use was consistent between periods (46% pre vs. 58% post; p = 0.18). Pre-ICP, use of the restrictive eating disorder protocol differed across services (p < 0.001), with only AM using it. Overall, utilization of the restrictive eating disorder protocol decreased from 16% pre-ICP to 2% post-ICP (p = 0.02). There was variation by service in psychiatry/psychology (range 82-100% by service; p = 0.09) and social work consultations (range 17-71% by service; p = 0.001) during the pre-ICP period, though variation was reduced in the post-ICP period (p = 0.99 and p = 0.05, respectively). Implementation of the ICP led to improvements in these consultative services, with all patients in the post-ICP period receiving psychiatry/psychology consultation (p = 0.05) and an increase in social work consults from 44 to 64% (p = 0.03). Nutrition consults were consistently utilized in both periods (98% pre vs. 100% post; p = 0.33). CONCLUSION: The ICP was developed to standardize inpatient medical stabilization for patients with ARFID. In this single center study, implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: there were improvements in the use of consulting services and a reduction in the use of the restrictive eating disorder protocol. The ICP demonstrates the potential to further standardize and improve care over time.

There is limited evidence to guide management of children and adolescents with Avoidant Restrictive Food Intake Disorder (ARFID) admitted for medical stabilization. The study describes the variation in inpatient care for ARFID, which led to the development of a multidisciplinary standardized inpatient clinical pathway (ICP). The ICP centers the experience of the patient and family with an emphasis on biopsychosocial support. Implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: There were improvements in the use of psychiatry/psychology and social work consulting services and a reduction in the use of the restrictive eating disorder protocol. Future research is needed to better understand the impact of the inpatient clinical pathway to improve care over time.

Conceptualizing avoidant/restrictive food intake disorder via an executive functioning lens.

Avoidant/restrictive food intake disorder (ARFID) is a heterogeneous disorder wherein restrictive eating is primarily attributed to non-shape/weight-based reasons (e.g., sensory sensitivity) that empirical research continues to explore. Mounting evidence suggests that ARFID often presents alongside neurodevelopmental diagnoses (NDs) or divergent neurodevelopment broadly. Executive functioning (EF) differences often characterize divergent neurodevelopmental trajectories. Additionally, restrictive eating in anorexia nervosa has been conceptualized as related to EF factors (e.g., set shifting). Given the neurodevelopmental phenotype that may be associated with ARFID and the role of EF in anorexia nervosa, this paper proposes EF as a potentially important, yet understudied factor in ARFID pathology. We posit that various observed ARFID behavioral/cognitive tendencies can be conceptualized in relation to EF differences. We contextualize commonly observed ARFID presentations within "core" EF components (i.e., cognitive flexibility, working memory, inhibitory control), leading to hypotheses about EF in ARFID. Finally, we offer additional considerations/directions for future research on EF in ARFID. Increased research on EF in ARFID is needed to consider this potential common factor in the etiology and maintenance of this heterogeneous disorder. We aim to promote further consideration of EF in ARFID etiology, maintenance, and treatment-outcome research. PUBLIC SIGNIFICANCE: This article proposes that aspects of executive functioning (EF) may play a role in the onset and maintenance of avoidant/restrictive food intake disorder (ARFID), although this notion is largely untested by existing research. Further research on the role of EF in ARFID may assist with refining models and treatments for this heterogeneous disorder.

A prospective observational study examining weight and psychosocial change in adolescent and adult eating disorder inpatients admitted for nutritional rehabilitation using a high-energy re-feeding protocol.

BACKGROUND: High-energy re-feeding protocols are increasingly utilised for nutritional rehabilitation in adolescents with anorexia nervosa (AN), however, concern persists that adults with AN may be at greater risk of developing complications. In addition, research on psychological outcomes of eating disorder (ED) inpatient treatment programs, and outcomes of high-energy protocols in avoidant restrictive food intake disorder (ARFID) and bulimia nervosa (BN), is limited. This study of an ED inpatient program using a high-energy protocol, compared changes in weight and psychosocial outcomes between adolescents and adults, and identified medical risk factors associated with deviation from the protocol. METHOD: This prospective observational study took place in a voluntary ED treatment program in a private hospital. Weight, height, and psychosocial questionnaires (ED Examination-Questionnaire, Depression Anxiety Stress Score, Clinical Impairment Assessment and AN/BN Stage of Change) were collected from consenting adolescents (16-20 years) and adults (> 20 years) on admission and discharge. Medical tolerance to the high-energy protocol was assessed daily. Independent samples t-tests and paired samples t-tests were applied to normally distributed data, and Mann-Whitney U tests and Wilcoxon signed-rank tests to skewed data. P-values < 0.05 were considered significant statistically. RESULTS: Ninety-seven participants were recruited. The majority (n = 91, 94%) were female and most (n = 80, 83%) had AN. Forty-two (43%) were adolescents and 55 (57%) were adults. In participants with AN, weight change (Δ) was significant [median Δ 8.0 (interquartile range (IQR) 4.3) kg]. There was no difference in rate of weight change between adolescents and adults with AN [mean Δ 1.8 (standard deviation (SD) 0.5) kg/week vs. Δ 1.8 (SD 0.6) kg/week; p = 0.841, respectively]. One (1%) participant with AN did not tolerate the high-energy protocol due to oedema. Participants achieved positive change in psychosocial questionnaire scores (p < 0.001) after the the specialist ED program, with no difference between adolescents and adults (p > 0.05). CONCLUSIONS: This voluntary ED treatment program using a high energy re-feeding protocol was effective in achieving positive weight and psychological change for adolescents and adults with minimal adverse events. This indicates that the specialist ED program has both nutritional and psychological benefits.

Nutritional recovery of adolescent inpatients with anorexia nervosa (AN) can be safely and effectively carried out using high-energy feeding protocols. However, not enough research has been done to support the use of these protocols in adults with AN, or people with avoidant restrictive food intake disorder (ARFID) and bulimia nervosa (BN). The psychological effects of using high-energy protocols for people with eating disorders (EDs) are also rarely reported. We aimed to find out a) if our high-energy re-feeding protocol is effective for adolescents and adults with AN, and for people with other EDs; b) are there any medical side-effects of re-feeding that require the feeding protocol to change; c) do psychosocial measures of health change from admission to discharge; and d) are there differences in weight or psychosocial change between adolescents and adults? We found that for adolescents and adults with AN, weight increases were the same when using the high-energy protocol. The protocol was changed for only one participant with AN, who experienced oedema. Both adolescents and adults had positive improvements across all psychosocial questionnaires. The results of this research will help to guide clinicians and researchers on safe and effective care for people with EDs in voluntary treatment settings.

Prospective 2-Year Course and Predictors of Outcome in Avoidant/Restrictive Food Intake Disorder.

OBJECTIVE: To evaluate the 2-year course and outcomes of full and subthreshold avoidant/restrictive food intake disorder (ARFID) in youth aged 9 to 23 years at baseline using a prospective longitudinal design to characterize the remission and persistence of ARFID, evaluate diagnostic crossover, and identify predictors of outcome. Greater severity in each ARFID profile-sensory sensitivity, fear of aversive consequences, and lack of interest-was hypothesized to predict greater likelihood of illness persistence, controlling for age, sex, body mass index percentile, ARFID treatment status, and baseline diagnosis. METHOD: Participants (N = 100; age range, 9-23 years; 49% female; 91% White) were followed over 2 years. The Pica, ARFID, and Rumination Disorder Interview was used across 3 time points (baseline, year 1, year 2) to measure the severity of each ARFID profile and evaluate illness persistence or remission, and the Eating Disorder Assessment for DSM-5 was used to evaluate diagnostic crossover. RESULTS: Across the 2-year follow-up period, half the participants persisted with their original diagnosis, and 3% of participants experienced a diagnostic shift to anorexia nervosa. Greater severity in the sensory sensitivity and lack of interest profiles was associated with higher likelihood of ARFID persistence at year 1 only; greater severity in the fear of aversive consequences profile was associated with higher likelihood of ARFID remission at year 2 only. CONCLUSION: Findings underscore the distinctiveness of ARFID from other eating disorders and emphasize its persistence over 2 years. Results also highlight the predictive validity and prognostic value of the ARFID profiles (ie, sensory sensitivity, fear of aversive consequences, lack of interest).

Course of avoidant/restrictive food intake disorder: Emergence of overvaluation of shape/weight.

BACKGROUND: Avoidant/restrictive food intake disorder (ARFID) is a feeding/eating disorder characterized by avoidance/restriction of food intake by volume and/or variety. The emergence of shape/weight-related eating disorder symptoms in the longitudinal course of ARFID is an important clinical phenomenon that is neither robustly documented nor well understood. We aimed to characterize the emergence of eating disorder symptoms among adults with an initial diagnosis of ARFID who ultimately developed other eating disorders. METHOD: Thirty-five participants (94% female; Mage = 23.17 ± 5.84 years) with a history of ARFID and a later, separate eating disorder completed clinical interviews (i.e., Structured Clinical Interview for DSM-5 - Research Version and Longitudinal Interval Follow-Up Evaluation) assessing the period between ARFID and the later eating disorder. Participants used calendars to aid in recall of symptoms over time. Descriptive statistics characterized the presence, order of, and time to each symptom. Paired samples t-tests compared weeks to emergence between symptoms. RESULTS: Most participants (71%) developed restricting eating disorders; the remainder (29%) developed binge-spectrum eating disorders. Cognitive symptoms (e.g., shape/weight concerns) tended to onset initially and were followed by behavioral symptoms. Shape/weight-related food avoidance presented first, objective binge eating, fasting, and excessive exercise occurred next, followed by subjective binge eating and purging. CONCLUSIONS: Diagnostic crossover from ARFID to another (typically restricting) eating disorder following the development of shape/weight concerns may represent the natural progression of a singular clinical phenomenon. Findings identify potential pathways from ARFID to the development of another eating disorder, highlighting possible clinical targets for preventing this outcome.

Co-existing mental and somatic conditions in Swedish children with the avoidant restrictive food intake disorder phenotype.

Background: Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder, characterized by limited variety and/or quantity of food intake impacting physical health and psychosocial functioning. Children with ARFID often present with a range of psychiatric and somatic symptoms, and therefore consult various pediatric subspecialties; large-scale studies mapping comorbidities are however lacking. To characterize health care needs of people with ARFID, we systematically investigated ARFID-related mental and somatic conditions in 616 children with ARFID and >30,000 children without ARFID. Methods: In a Swedish twin cohort, we identified the ARFID phenotype in 6-12-year-old children based on parent-reports and register data. From >1,000 diagnostic ICD-codes, we specified mental and somatic conditions within/across ICD-chapters, number of distinct per-person diagnoses, and inpatient treatment days between birth and 18th birthday (90 outcomes). Hazard ratios (HR) and incidence rate ratios (IRR) were calculated. Findings: Relative risks of neurodevelopmental, gastrointestinal, endocrine/metabolic, respiratory, neurological, and allergic disorders were substantially increased in ARFID (e.g., autism HR[CI95%]=9.7[7.5-12.5], intellectual disability 10.3[7.6-13.9], gastroesophageal reflux disease 6.7[4.6-9.9], pituitary conditions 5.6[2.7-11.3], chronic lower respiratory diseases 4.9[2.4-10.1], epilepsy 5.8[4.1-8.2]). ARFID was not associated with elevated risks of autoimmune illnesses and obsessive-compulsive disorder. Children with ARFID had a significantly higher number of distinct mental diagnoses (IRR[CI95%]=4.7[4.0-5.4]) and longer duration of hospitalizations (IRR[CI95%]=5.5[1.7-17.6]) compared with children without ARFID. Children with ARFID were diagnosed earlier with a mental condition than children without ARFID. No sex-specific differences emerged. Interpretation: This study yields the broadest and most detailed evidence of co-existing mental and somatic conditions in the largest sample of children with ARFID to date. Findings suggest a complex pattern of health needs in youth with ARFID, underscoring the critical importance of attention to the illness across all pediatric specialties. Funding: Fredrik and Ingrid Thurings Foundation, Mental Health Foundation.

Moderating effect of self-esteem between perfectionism and avoidant restrictive food intake disorder among Lebanese adults.

BACKGROUND: Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis added to the DSM-5 characterized by pathological eating habits without body image disturbances. Previous findings demonstrated a general association between high levels of perfectionism and low levels of self-esteem in association with general eating disorders. However, research is scant when it comes to ARFID specifically. Subsequently, although self-esteem is seen to moderate the association between perfectionism and general eating disorders, this research study aims to explore the same moderation but with ARFID specifically. METHODS: For this study, 515 Lebanese adults from the general Lebanese population were recruited from all over Lebanon, 60.1% of which were females. The Arabic version of the Big Three Perfectionism Scale- Short Form (BTPS-SF) was used to measure self-critical, rigid and narcissistic perfectionism; the Avoidant/Restrictive Food Intake Disorder screen (NIAS) was used to score the ARFID variable; the Arabic-Single Item Self-Esteem (A-SISE) was the scale used to measure self-esteem. RESULTS: Across the different perfectionism types, self-esteem was seen to moderate the association between narcissistic perfectionism and ARFID (Beta = - 0.22; p =.006). At low (Beta = 0.77; p <.001), moderate (Beta = 0.56; p <.001) and high (Beta = 0.36; p =.001) levels of self-esteem, higher narcissistic perfectionism was significantly associated with higher ARFID scores. CONCLUSION: This study brought to light some crucial clinical implications that highlight the need for interventions that help in the enhancement of self-esteem in patients with high perfectionism and ARFID. This study suggests that clinicians and healthcare professionals should focus more on risk factors influencing the development and maintenance of ARFID-like symptoms.

Lifetime and current mental health based on avoidant/restrictive food intake disorder history versus other eating disorder history in the Healthy Minds Study.

OBJECTIVE: Research on psychiatric comorbidities associated with avoidant/restrictive food intake disorder (ARFID) primarily compares ARFID versus anorexia nervosa (AN). Little is known about comorbidities associated with mixed ARFID/other eating disorder (ED) history or ARFID comorbidities relative to EDs beyond AN. This study assessed lifetime and current psychiatric factors in a large college sample with varying ED histories. METHOD: Participants were United States students from the 2021/2022 Healthy Minds Study who endorsed lifetime professionally diagnosed EDs (N = 4657). Chi-square tests compared lifetime ED groups (ARFID, ARFID + Non-ARFID ED, Non-ARFID ED) on lifetime neurodevelopmental, anxiety, obsessive-compulsive, trauma/stressor-related, and depressive disorder prevalence, and suicidality and counseling/therapy receipt. Multivariate analysis of variance evaluated current depressive, anxiety, and ED symptom differences. RESULTS: Lifetime neurodevelopmental and anxiety disorders were less prevalent in "Lifetime Non-ARFID ED" than ARFID groups. Lifetime depressive, trauma/stressor-related, and obsessive-compulsive disorders were relatively more prevalent in "Lifetime ARFID + Non-ARFID ED." This group demonstrated relatively greater current depressive symptoms and past-year suicide attempts. Lifetime ARFID groups demonstrated relatively greater current anxiety. All groups differed on current ED symptoms. Effects were small. DISCUSSION: Historical ARFID is associated with neurodevelopmental disorders and historical/current anxiety. Mixed ARFID/non-ARFID ED history may indicate increased propensity toward varied psychopathology. PUBLIC SIGNIFICANCE STATEMENT: This study replicated findings that ARFID is associated with neurodevelopmental and anxiety disorders in the lifespan through young adulthood. Extending prior work, results suggest a history of ARFID is associated with increased anxiety in young adulthood. Finally, a history of both ARFID and other eating pathology is associated with increased risk for a wide range of psychiatric difficulties (e.g., obsessive-compulsive symptoms, suicide attempts) in the lifespan through young adulthood.