Avoidant Restrictive Food Intake Disorders in GI Patients

Dr. Nandi:
You’re listening to GI Insights on ReachMD. I’m Dr. Neil Nandi, and on this program, we’re gonna hear from Dr. Tiffany Taft on ARFID, Avoidant Restrictive Food Intake Disorder. This is not anorexia, while there may be some similarities; this is a distinct entity that all clinicians and especially GIs should be aware of. If you have patients on a number of elimination diets or ever wondered why your workup for weight loss has turned up negative, then listen up. Dr. Taft is going to discuss Avoidant Restrictive Food Intake Disorder, or ARFID for short, and its impact on GI disorders. Let’s hear from Dr. Taft now. Dr. Taft, how is ARFID, Avoidant Restrictive Food Intake Disorder, different from anorexia? 

Dr. Taft:
Yeah, thank you for having me to talk about this important and new topic within GI. So, ARFID is a condition where the restriction of food is not driven by body image concerns that we would see in someone with anorexia or bulimia, for example. It is driven by the need to control their symptoms and so people are restricting their diet, avoiding foods to avoid having uncomfortable symptoms, whether it’s an esophageal condition like acolasia, all the way down through IBD and IBS. So, we see ARFID behaviors in every GI diagnosis that comes into our practice.

Dr. Nandi:
Yeah, and just to elaborate, there’s so many elimination diets that our patients are pursuing, you know, whether it’s for medical purposes, such as sick-food elimination or eosinophilic esophagitis or gluten-free diets, be it they have celiac, or low-FODMAP diet, which is very, very popular for a number of patients, not just within the IBS and bloating realm. What should doctors look out for when having patients on these types of diets and being mindful whether a patient may or may not have ARFID?

Dr. Taft:
I think the number 1 thing to assess when prescribing a diet is the patient’s baseline level of symptom-specific anxiety or anxiety about their condition. And that might not be obvious in your interaction with the patient in the clinical encounter, but asking a couple of questions about how worried they are, how their symptoms are affecting their life, especially around food, and if you can get a quick assessment of that, then I would say it becomes a decision point of, “Do I recommend the low-FODMAP diet, or is there some mitigation of that anxiety that needs to happen first, before we go down that path?” 

Dr. Nandi:
So when we have a restrictive diet, weight loss is, obviously, a leader end-point that is very concerning. Are there certain answers or other types of responses when asking a patient about their dietary habits that would really clue you in that they may be at risk or would you suggest that a GI, like myself, refer to a clinician?

Dr. Taft:
I think it can be done, you know, with the gastroenterologist first. So, for example on the FODMAP diet, the design is a period of exclusion with a reintroduction phase and so one red flag is a patient’s refusal to reintroduce foods after that one month-ish phase of taking the foods out under the FODMAP plan. So, that is a rigidity of, ‘I’m not gonna bring these foods back because I feel better and I’m afraid that if I bring these back…’, or maybe they even tried a couple of times and it didn’t go well, so that’s one of the red flags that we look for. Whether it’s FODMAP or other diets where there is a reintroduction phase, that would be an indication of more conversation about why the person is afraid to or is refusing to reintroduce foods.

Dr. Nandi:
That’s very important. Are there any particular resources that a physician can learn more about ARFID? How much literature and study has been done upon this in our GI patients? 

Dr. Taft:
Not a lot (laughter). There’s a handful of studies on ARFID, right now, mostly in patients with irritable bowel syndrome. There are a few in inflammatory bowel disease and I think there’s one in gastroparesis and so the rates we see in those conditions are anywhere between 15% to the 40% level seen in the gastroparesis study, granted that’s one study. So, that points to, unfortunately, problems in diagnosing ARFID using the typical scale that is used, the NIAS, the 9-item ARFID scale, that is not validated in GI, so there are efforts going on in different centers across the country to get better resources for gastroenterologists in the clinic to be able to try and assess this better and then also getting a list of resources of dieticians, psychologists, who can help if a patient gets into trouble.

Dr. Nandi:
OK. So to clarify and repeat, ARFID, or Avoidant Restrictive Food Intake Disorder, is not anorexia, patients are not concerned about their body image, but they are restricting their diet and we often see this in our GI clinic following special types of elimination or restrictive diets without reintroducing good food and nutrition. Dr. Taft, I’m really thankful that you brought this to our attention that our patients are at risk for this. Do you have any closing suggestions or remarks for how clinicians can be mindful to look for ARFID?

Dr. Taft:
I think my main concern about ARFID is how serious it can get with our patients, but also not to fall into a pattern of over-pathologizing relatively reasonable behavior. If you feel sick, eating is not necessarily at the top of your priority list. So, I wanna emphasize, don’t diagnosis ARFID unless you are absolutely sure this is way beyond what would be considered reasonable and in the light of things like nutritional deficiency, significant weight loss, you know, marked impairment in their daily functioning, ‘cause some restriction is normal. But we really wanna be careful because of the stigma of eating disorders to not label these patients in that type of way but in a helpful way to get them back on track with eating.

Dr. Nandi:
Indeed. Yeah, so being careful to make the right diagnosis, but don’t be too eager to give this diagnosis because it is a label and there is a stigma, in general. That was Dr. Tiffany Taft, Director of Psycho-Gastroenterology Research in the Division of GI and Hepatology from Northwestern University, talking about the impact of Avoidant Restrictive Food Intake Disorders, ARFID in gastrointestinal health. To access this and other episodes from this series, visit ReachMD.com/GIInsights. I’m Dr. Neil Nandi, thanks for listening.