HealthNuts Study Links Food Allergy and Possible ARFID

Key Takeaways

• Among 10-year-olds in HealthNuts, possible ARFID prevalence by food allergy status was reported in 23% (95% CI 15–32) of children with current food allergy versus 21% (95% CI 18–24) of children without food allergy, with an odds ratio of 1.09 (95% CI 0.67–1.80).
• When food allergy anxiety was allowed to count as a fear-based ARFID variant, 10 additional children with current food allergy were identified and the subgroup estimate rose to 32% (95% CI 24–42).
• The paper reports screening-based possible ARFID rather than clinical diagnoses; overall possible ARFID across the analytic sample was 21% (204/951; 95% CI 19–24), and among children with current food allergy, 21 of 102 reported food allergy anxiety, with 76% of those children classified as possible ARFID-FAA.

Restrictive-eating symptoms screened by EDY-Q were similarly common in children with and without current food allergy in the age-10 HealthNuts analysis. Among 951 children who completed the EDY-Q, including 102 with current food allergy, possible ARFID was reported in 23% versus 21%, with an odds ratio of 1.09 (95% CI 0.67–1.80). The authors also explored a measurement gap by examining whether food allergy anxiety captured additional children within the food-allergy subgroup.

HealthNuts is a population-based prospective cohort that recruited 5276 one-year-olds in Melbourne and followed them at ages 4, 6, and 10 years; 88% remained contactable at age 10 (4,645/5,276). Current food allergy at age 10 was defined as definite or probable food allergy using skin prick tests, clinical history, and/or oral food challenges across follow-up. As described in HealthNuts methods and the exploratory ARFID-FAA definition, EDY-Q was used as a screening tool rather than a diagnostic interview, and the primary possible ARFID definition required disinterest in food, sensory food avoidance, or fear of choking or vomiting rated at least often, with weight and shape concern items below the exclusion threshold. The analysis therefore reports possible ARFID rather than confirmed diagnoses.

The investigators then defined ARFID-FAA by allowing a parent-reported FAQLQ-PF item on food allergy anxiety to count as a fear-based variant, using a cutoff of at least quite a bit on that item. That extension identified 10 additional children with current food allergy and increased the possible ARFID-FAA estimate in that subgroup to 32% (95% CI 24–42). Among children with current food allergy, 21 of 102 reported food allergy anxiety, and 76% of those children were classified as possible ARFID-FAA. In children with current food allergy who had presentation data available, sensory sensitivity was reported in 18 of 31 and food allergy anxiety in 16 of 31, with combined presentations most common at 13 of 31, followed by fear-based presentations at 12 of 31, sensory presentations at 5 of 31, and lack-of-interest presentations at 1 of 31.

The authors said EDY-Q may miss fear of allergic reactions in children with food allergy because that concern is not directly captured by the tool. They also described ARFID-FAA as exploratory because it relied on a parent-reported FAQLQ-PF item and a study-defined cutoff rather than a diagnostic standard, and it could not be compared in children without food allergy because the anxiety item was collected only in those with reported food allergy. The age-10 analytic sample was also a subset of follow-up participants because EDY-Q was added partway through the study, with attrition leaving over-representation of allergic disease history and higher socioeconomic status. The reported pattern was that the standard screen showed similar prevalence by food-allergy status, while the anxiety-inclusive definition identified additional children within the food-allergy subgroup.

Clinician Questions

How common was possible ARFID in 10-year-old children with current food allergy compared with those without food allergy?

In the age-10 HealthNuts analysis, EDY-Q screening-based possible ARFID was reported in 23% of children with current food allergy and 21% of children without food allergy, with an odds ratio of 1.09 and 95% CI 0.67–1.80. These were possible ARFID estimates from a screening tool rather than clinical diagnoses.

What happened to the ARFID estimate when food allergy anxiety was counted as a fear-based ARFID variant?

When the study-defined ARFID-FAA construct counted food allergy anxiety as a fear-based variant, it identified 10 additional children with current food allergy and increased the subgroup prevalence estimate to 32% (95% CI 24–42). This construct was exploratory and was based on a parent-reported FAQLQ-PF item on food allergy anxiety.

How was possible ARFID defined in the HealthNuts age-10 analysis?

The HealthNuts age-10 analysis used EDY-Q as a screening tool rather than a diagnostic interview. Possible ARFID required disinterest in food, sensory food avoidance, or fear of choking or vomiting rated at least often, with weight and shape concern items rated less than sometimes, and the study’s primary definition did not require underweight.

What ARFID-FAA features were most common among children with current food allergy?

Among children with current food allergy and available ARFID-FAA phenotype data, sensory sensitivity was reported in 18 of 31 and food allergy anxiety in 16 of 31. Combined presentations were most common at 13 of 31, followed by fear-based presentations at 12 of 31, sensory at 5 of 31, and lack of interest at 1 of 31.