Imagine a world where the sight, smell, or texture of most foods triggers intense anxiety or disgust. For individuals with avoidant/restrictive food intake disorder (ARFID), this is their everyday reality. Avoidant/restrictive food intake disorder (ARFID), sometimes described as “selective eating disorder,” is a complex condition that goes beyond simple picky eating.
This disorder is characterized by a persistent failure to meet nutritional needs, often resulting in significant weight loss, undernutrition, or even dependence on nutritional supplements or tube feeding.
Unlike some other eating disorders, HRAFD does not arise from concerns about body image or a desire to lose weight. Instead, individuals with HRAFD may avoid eating foods due to sensory sensitivities, fear of choking or vomiting, or a general lack of interest in eating. This can lead to severely restrictive dieting, social isolation, and significant health complications.
As awareness of avoidant food disorder increases, it is essential for both the public and healthcare professionals to understand its symptoms, challenges, and effective coping strategies.
What causes silent eating disorder or ARFID?
It is estimated that between 0.5% and 5% of children and adults suffer from food avoidance disorder and food withdrawal.1 It is a relatively new diagnosis, having been added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — a publication of the American Psychiatric Association that provides standardized criteria for classifying and diagnosing mental health disorders — in 2013.2
“I like to call this the silent eating disorder because it’s so prevalent, but it’s the least studied, the least talked about, and the least funded in federal research,” Stuart Murray, an assistant professor of psychiatry and behavioral sciences at the University of Southern California and director of the Laboratory for Translational Research in Eating Disorders, told CNN.3
The exact causes of eating disorders are not fully understood, but research suggests that they may result from a complex interaction of biological, psychological, and environmental factors. Biological factors may include sensory sensitivities, genetic predisposition, and neural differences in taste or smell processing.
Hormonal studies have also found abnormally high levels of substances that promote satiety (such as peptide YY, cholecystokinin, and oxytocin) and low levels of hunger-stimulating hormones (such as ghrelin) in ARFID patients, which may contribute to the development or persistence of the disorder.4
Psychological factors often play an important role as well,5 With avoidant and associated distress disorder frequently co-occurring with anxiety disorders, autism spectrum disorders, or obsessive-compulsive tendencies. For example, a systematic review published in European Eating Disorders Review found that anxiety disorders occur in 9% to 72% of people with avoidant and associated distress disorder, while autism affects between 8% and 54.75% of people with avoidant and associated distress disorder.6
Traumatic experiences with food, such as choking incidents, can also contribute to its development. Jennifer Thomas, of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, explained in the journal Psychiatric Annals:7
“One of the first patients I saw with avoidant/restrictive food intake disorder (ARFID) was an 11-year-old girl who came to my hospital’s eating disorders clinic with sudden weight loss. She had recently choked on a slice of ham during a family dinner, and then developed an intense fear of eating most solid foods. She told me, wide-eyed, that she was afraid to eat even a single grain of rice.
As I reviewed her history, I learned from her parents that she had been a “picky eater” her entire life (with a strong preference for simple foods like pasta with butter) and had always had a small appetite.
Unlike most of the patients we saw in our clinic at the time, this girl was severely distressed by her weight loss and was anxious to regain it. Her clinical presentation thus stood in stark contrast to most of our other patients, whose eating disorder behaviors were driven in part by an unrelenting desire to be thin.
Environmental factors, including early feeding difficulties, parental anxiety about nutrition, or limited exposure to a variety of foods in early childhood, may also increase the risk of developing avoidant food intolerance disorder (ARFID).8
Additionally, certain temperamental traits such as high sensitivity, rigidity in routine, or perfectionism may make individuals more susceptible to this disorder. It is important to note that avoidant eating disorder can develop at any age and is not always linked to a specific triggering event, making each case unique in its origins and manifestations.
What are the signs and symptoms of ARFID?
Symptoms of this condition vary from person to person, but there are several common signs and symptoms to look out for. The most obvious is a very restrictive diet, often limited to a small number of “safe” foods. These safe foods may be a certain color, texture, or brand. Individuals with avoidant food disorder may reject entire food groups, such as fruits, vegetables, or proteins, leading to nutritional imbalances.
But avoidant-selective eating disorder is not just about selective eating, it’s about debilitating levels of food avoidance. “A person with a picky eating disorder may be able to eat a certain food on their plate, or they may be able to eat a little bit of it. A person with avoidant-selective eating disorder may not be able to eat anything on their plate if there’s a food on the plate that they consider unacceptable,” Murray told CNN.9
Physical symptoms of ARFID may include significant weight loss or, in children, failure to gain weight or grow as expected. Digestive problems are also common, as are signs of malnutrition such as fatigue, weakness, or hair loss. In severe cases, individuals may need nutritional supplements or even feeding tubes to maintain their health.
Emotionally and behaviorally, people with avoidant food and associated distress disorder often show high levels of anxiety about food and eating situations. They may avoid social events that involve eating, have difficulty eating in public, or feel panic when presented with new or frightening foods.
Unlike people with anorexia nervosa, people with food avoidance and craving disorder do not express concerns about body image or weight gain. Instead, their avoidance of food may stem from a fear of choking, vomiting, or experiencing other negative consequences from eating.
Living with ARFID involves health risks and social obstacles.
Individuals with severe eating disorders face multiple challenges that extend beyond eating. The severely restricted diets characteristic of severe eating disorders can lead to significant nutritional deficiencies, which can lead to a range of health complications. These complications may include:10
Anemia | Weak immune system |
Osteoporosis | electrolyte imbalance |
low blood pressure | Cardiac arrest |
Delayed puberty | organ damage |
Growth retardation is common in children with avoidant eating disorder or gastroesophageal reflux disease, while adults may experience unhealthy weight loss and muscle wasting. Deficiencies in essential nutrients can also affect cognitive function, leading to difficulties with concentration, memory, and overall mental acuity.
Furthermore, social situations often become a source of intense anxiety for people with avoidant eating disorder. Participating in social gatherings, or even family meals, can be extremely stressful experiences. This social isolation can lead to feelings of loneliness, depression, and low self-esteem. In professional settings, food-focused lunches or team-building events can become obstacles to career advancement.
For children and teens, school cafeterias and birthday parties can be particularly challenging, affecting their social development and relationships with peers. The psychological impact of avoidant eating disorder should not be underestimated. Many individuals with this disorder experience intense anxiety about food, which can spill over into other areas of life.
Constant anxiety about encountering unfamiliar foods or being pressured to eat them can be stressful and confusing. chronic stress This can worsen existing mental health conditions or contribute to the development of new ones.
Additionally, misunderstanding and lack of awareness surrounding avoidant or anxious eating disorder can lead to feelings of frustration and isolation, as individuals may feel that others do not understand or take their struggle seriously. This can create barriers to seeking help and support, which can prolong the duration and severity of the disorder. Claire Lidstrand, who has avoidant or anxious eating disorder, told Inspire the Mind:11
“It can be very lonely when you live with avoidant eating disorder. Many social events revolve around food, so it is almost impossible to avoid questions about eating. As a result, social anxiety often coexists with avoidant eating disorder because people become more self-conscious about their eating.
It doesn’t help that our choices are constantly scrutinized by those around us. People often comment on my portion sizes… or the lack of seasoning in my food. And while I’m usually open to answering questions and helping people understand, I’m not always willing to discuss the details of my disorder with strangers…
Eating in private is often easier than answering questions or hearing other people’s comments… The process of… eating… in public can be incredibly stressful, making doing so an act of courage for many of us.”
Natural ways to treat ARFID
Treatment for avoidant and binge eating disorder typically involves a multidisciplinary approach that combines psychological interventions and nutritional support. Cognitive behavioral therapy, which helps modify behaviors, thoughts, and emotions, and is adapted for avoidant and binge eating disorder, has shown promising results.12
This therapy helps individuals challenge and change their negative thoughts and behaviors around food. Exposure therapy is a key component of cognitive behavioral therapy for acute avoidant food disorders.13 This program gradually introduces foods that the patient fears or avoids in a controlled, supportive environment. This gradual approach helps individuals build confidence and reduce anxiety about eating.
Family-based therapy, originally developed to treat anorexia nervosa, has been modified to treat avoidant food intake disorder (ARFID) with positive results, especially for young children.14 This approach involves involving the entire family in the treatment process, educating them about the disorder and teaching them strategies to support the individual at home. Parents or caregivers play a critical role in planning meals, encouraging them, and creating a positive environment for eating.
Additionally, occupational therapy can be helpful, especially for those with sensory sensitivities.15 Occupational therapists can work on desensitization techniques and help individuals develop strategies for coping with difficult food textures or smells.
Nutritional counseling is another cornerstone of avoidant eating disorder treatment. A holistic health care practitioner can work with the individual to gradually expand their diet while ensuring that nutritional needs are met.
This may include creative meal planning, food sequencing,16 – Associate acceptable foods with new foods with similar properties – and supplement recommendations when necessary. Some find success with mindfulness and relaxation techniques, which can help manage anxiety around eating.
Yoga, meditation, and breathing exercises can also be valuable tools in reducing stress and creating a more positive relationship with food. While recovery from avoidant eating disorder can be a long process, these natural approaches offer hope and have helped many individuals expand their diets and improve their quality of life.
