An Inpatient Observational Study: Characteristics And Outcomes Of Avoidant/Restrictive Food Intake Disorder (ARFID) In Children And Adolescents In Japan

Does multimodal inpatient treatment help some adolescents with severe ARFID?

INTRODUCTION

Avoidant Restrictive Food Intake Disorder (ARFID) is a recently described disorder. Data on inpatient treatment is still scarce, ARFID mainly being an outpatient condition. The purpose of this study is to describe a rare population of adolescents with severe ARFID receiving full-time multimodal inpatient care by examining their clinical characteristics, management, and evolution.

METHODS

We conducted a retrospective study on a series of patients diagnosed with ARFID who were hospitalised from 2005 to 2022. This study was carried out at the Adolescent Medicine department of a University Hospital in Paris, France, specialising in the treatment of eating disorders.

RESULTS

Sixteen adolescents aged 12 to 17 were hospitalised for severe ARFID associated with malnutrition, growth retardation, pubertal delay, and/or psychiatric comorbidities. All but one had body mass indexes less than -2 standard deviations. Mean BMI upon admission was 14,1 [standard deviation=1,8]. They benefited from multimodal treatment plans supported by a multidisciplinary team, including nutritional, somatic and psychiatric transdisciplinary assessment and care, residential care, and family involvement. Length of stay was five months on average, and 50% had achieved normal body mass index at discharge.

CONCLUSIONS

Full-time inpatient care with multimodal and multidisciplinary interventions and tailored management can help restore normal weight for some adolescents. These interventions are aimed at patients with severe ARFID with major complications such as stunted growth and delayed puberty, and/or comorbidities such as depression. Specific subtypes of patients with severe ARFID need to be identified to delineate their characteristics, prognosis, and treatments effective for this group.

Physical health complications in children and young people with avoidant restrictive food intake disorder (ARFID): a systematic review and meta-analysis

BACKGROUND

Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder with known acute and longstanding physical health complications in children and young people (CYP) and commonly presents to paediatricians.

OBJECTIVE

To systematically review the published literature on physical health complications in CYP with ARFID using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A systematic search of PubMed, Embase, Web of Science, PsycINFO and Cochrane Library was performed on 14 February 2024. Studies reporting physical health complications in CYP ≤25 years with ARFID were included. We pooled studies for meta-analysis comparing ARFID with healthy controls or anorexia nervosa (AN).

RESULTS

Of 9058 studies found in searches, we included 132 studies. We found evidence for low weight, nutritional deficiencies and low bone mineral density. CYP with ARFID can present across the weight spectrum; however, the majority of CYP with ARFID were within the healthy weight to underweight range. Most studies reported normal range heart rates and blood pressures in ARFID, but some CYP with ARFID do experience bradycardia and hypotension. CYP with ARFID had higher heart rates than AN (weighted mean difference: 12.93 bpm; 95% CI: 8.65 to 17.21; n=685); heterogeneity was high (I2: 81.33%).

CONCLUSION

There is a broad range of physical health complications associated with ARFID requiring clinical consideration. Many CYP with ARFID are not underweight yet still have complications. Less cardiovascular complications found in ARFID compared with AN may be related to chronicity.

PROSPERO REGISTRATION NUMBER

CRD42022376866.

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.

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).

The effectiveness and cultural adaptations of psychological interventions for eating disorders in East Asia: A systematic scoping review

OBJECTIVE

There has been no review on eating disorder-focused psychological interventions in East Asia. The aims of this systematic scoping review were to summarize existing and forthcoming studies and to synthesize the cultural adaptations and effectiveness of the interventions identified.

METHOD

Five databases (PubMed, Embase, Global Health, Medline, PsychInfo) and seven trial registries were searched. Studies examining eating disorder (ED)-focused psychological interventions in East Asia were included. Narrative synthesis was used for the analysis.

RESULTS

Eighteen published studies and 14 ongoing/completed but unpublished studies were included. Most published studies were uncontrolled and five were feasibility studies. Among the ongoing studies, 71% are randomized controlled trials. Cognitive therapies were the main approach used, including individual cognitive behavioral therapy (CBT), internet CBT, group CBT, guided self-help, and cognitive remediation therapy. Cultural adaptations were mostly related to language, communication style and tailoring the dietary requirements to local diets. Interventions were shortened to increase acceptability and reduce financial and time burden to patients. Overall, studies showed good acceptability, completion rates and positive effects on ED symptoms (indicated by moderate to large effect sizes or statistical significance).

DISCUSSION

Studies were underpowered and uncontrolled, thus precluding meaningful interpretations of effectiveness to be made. However, the psychological interventions were acceptable and showed promise in delivery. Digital and group interventions seemed to be the most feasible given barriers in the local health systems. More controlled studies, as well as studies on children and adolescents, are needed in future.

PUBLIC SIGNIFICANCE

This is the first systematic scoping review examining psychological interventions for eating disorders in East Asia. Research in eating disorders has largely focused on White people and in Western countries. This review will be helpful for clinicians and researchers to understand the current state of the field through a non-Eurocentric lens, to identify gaps and plan future research.

Inpatient hospital course and self-reported symptomatology in underweight adults with ARFID compared to age- and sex-matched controls with anorexia nervosa

OBJECTIVE

Avoidant restrictive food intake disorder (ARFID) has similar prevalence to anorexia nervosa (AN) in adults, but research in this population is lacking. Although inpatient or residential treatment involving nutritional rehabilitation is increasingly recommended for malnourished individuals with ARFID, best practices remain poorly defined. Existing studies on self-reported symptomatology and treatment course and outcome are primarily in child and adolescent cohorts and demonstrate inconsistent findings. This study aimed to compare hospital course and self-reported symptomatology of underweight adult inpatients with ARFID and sex- and age-matched patients with AN.

METHOD

Underweight adult patients with ARFID or AN admitted to a specialized, hospital-based behavioral treatment program completed measures of body dissatisfaction, drive for thinness, bulimic symptoms, anxiety, depression, and personality traits. Demographic and treatment course data were abstracted from electronic medical records. Patients with ARFID (n = 69) were matched to those with AN (n = 69) based on sex and age.

RESULTS

Adults with ARFID were closer to target weight at admission, but gained weight at a slower rate, were discharged at lower BMI, and were less likely to reach target weight by discharge than adults with AN. Patients with ARFID reported less weight and shape-related eating disorder, state anxiety, and depression symptoms and lower neuroticism.

DISCUSSION

Adults with ARFID progress through treatment more slowly and achieve less favorable weight outcomes by hospital discharge than patients with AN, but long-term outcomes are unclear. Describing clinical presentations and course of illness of adult ARFID may help inform treatment protocols.

A Systematic Review to Manage Avoidant/Restrictive Food Intake Disorders in Pediatric Gastroenterological Practice

Avoidant/Restrictive food intake disorder (ARFID) is a feeding disorder characterized by persistent difficulty eating, such as limited choices of preferred foods, avoidance or restriction of certain foods or food groups, and negative emotions related to eating or meals. Although ARFID mainly affects children, it can also occur in adolescents and adults. ARFID can have serious physical and mental health consequences, including stunted growth, nutritional deficiencies, anxiety, and other psychiatric comorbidities. Despite its increasing importance, ARFID is relatively underrecognized and undertreated in clinical practice. Treatment consists of a multidisciplinary approach involving pediatric gastroenterologists, nutritionists, neuropsychiatrists, and psychologists. However, there are several gaps in the therapeutic approach for this condition, mainly due to the lack of interventional trials and the methodological variability of existing studies. Few studies have explored the nutritional management of ARFID, and no standardized guidelines exist to date. We performed a systematic literature review to describe the different nutritional interventions for children and adolescents diagnosed with ARFID and to assess their efficacy and tolerability. We identified seven retrospective cohort studies where patients with various eating and feeding disorders, including ARFID, underwent nutritional rehabilitation in hospital settings. In all studies, similar outcomes emerged in terms of efficacy and tolerability. According to our findings, the oral route should be the preferred way to start the refeeding protocol, and the enteral route should be generally considered a last resort for non-compliant patients or in cases of clinical instability. The initial caloric intake may be adapted to the initial nutritional status, but more aggressive refeeding regimens appear to be well tolerated and not associated with an increased risk of clinical refeeding syndrome (RS). In severely malnourished patients, however, phosphorus or magnesium supplementation may be considered to prevent the risk of electrolyte imbalance, or RS.

Current evidence for avoidant restrictive food intake disorder: Implications for clinical practice and future directions

Background

ARFID (avoidant restrictive food intake disorder) is a relatively new diagnostic term covering a number of well-recognised, clinically significant disturbances in eating behaviour unrelated to body weight/shape concerns. Its phenotypic heterogeneity combined with much about the condition remaining unknown, can contribute to uncertainties about best practice. While other reviews of the evidence base for ARFID exist, few specifically target health care professionals and implications for clinical practice.

Methods

A narrative review was conducted to synthesise the findings of ARFID papers in scientific journals focussing on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Freely available online databases were searched for case studies and series, research reports, review articles, and meta-analyses. Findings were reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions.

Results

We discuss what is currently known about the four key areas included in this review. Based on available evidence as well as gaps identified in the literature, recommendations for clinical practice are derived and practice-related research priorities are proposed for each of the four of the areas explored.

Conclusion

Prevalence studies highlight the need for referral and care pathways to be embedded across a range of health care services. While research into ARFID is increasing, further studies across all areas of ARFID are required and there remains a pressing need for guidance on systematic assessment, evidence-based management, and optimal service delivery models. Informed clinical practice is currently predominantly reliant on expert consensus and small-scale studies, with ongoing routine clinical data capture, robust treatment trials and evaluation of clinical pathways all required. Despite this, a number a positive practice points emerge.

A Seven-Year-Old Girl With Dysphagia Due to Fear of Swallowing: A Favorable Outcome With Cognitive Behavioral Therapy Using an Anxiety Hierarchy Chart

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder characterized by avoidance and aversion to food and eating. Food restriction is not due to a body image disturbance but rather to an anxiety or phobia of food and eating or abnormal hypersensitivity to food, such as its texture, taste, or smell, or a lack of interest in food/eating. We herein report a seven-year-old girl with dysphagia due to a fear of swallowing with a favorable outcome thanks to cognitive behavioral therapy using an anxiety hierarchy chart. After a scary experience of seeing her bother choking on a sausage, the patient struggled with a strong fear of eating, especially swallowing, and was diagnosed with ARFID. We constructed a hierarchical chart of food insecurity, listing her favorite sweets in order, from soft to hard. She picked out daily sweets and snacks from the list. She gradually learned to eat hard-shaped food, achieved an adequate oral calorie intake, and was discharged on the twenty-second hospital day. This case indicates that cognitive behavioral therapy using the anxiety hierarchy chart can be applied to the treatment of school-age children with ARFID.

Weight Gain in Adults with Avoidant/Restrictive Food Intake Disorder Compared to Restrictive Anorexia Nervosa-Pilot Findings from a Longitudinal Study

BACKGROUND

Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by persistent failure to meet nutritional needs, absence of body image distortion and often low body weight. Weight restorative treatment in ARFID-adults is provided for as in Anorexia Nervosa (AN), while the effect is unknown. The aim was to compare weight gain between ARFID and restrictive subtype of AN (AN-R), including exploring impact of medical factors and psychopathology.

METHODS

Individuals with ARFID (n = 7; all cases enrolled over 5 years) and AN-R (n = 80) were recruited from the Prospective Longitudinal All-comers inclusion study in Eating Disorders (PROLED) during 5 years. All underwent weight restorative inpatient treatment. Clinical characteristics at baseline and weekly weight gain were recorded and compared.

RESULTS

There were no significant differences at baseline weight, nor in weight gain between groups. Anxiety was statistically significantly higher in AN-R at baseline.

CONCLUSIONS

Although there were differences in several clinical measures at baseline (Autism Quotient, symptom checklist, mood scores and Morgan Russel Outcome Scale), only anxiety was higher in AN-R. No differences in weight gain were observed, although mean values indicate a faster weight gain in the ARFID group. Standard weight restorative treatment in this study in adults with ARFID has similar weight gaining effect as in AN-R.

The changing profile of eating disorders and related sociocultural factors in Japan between 1700 and 2020: A systematic scoping review

OBJECTIVE

The purpose of this study was to investigate the changing profile of the phenotypic expression of eating disorders (EDs) and related sociocultural factors in Japan between 1700 and 2020.

METHOD

The authors conducted a systematic scoping review in accordance with the PRISMA statement guidelines for scoping reviews.

RESULTS

Findings indicate that Kampo doctors reported more than 50 patients with restrictive EDs in the 1700s, when Japan adopted a national isolation policy. On the other hand, only a few reports of EDs were found between 1868 and 1944, when rapid Westernization occurred. After World War II, providers began diagnosing patients with anorexia nervosa (AN) around 1960. Patients reported experiencing fat phobia, but did not engage in restriction for achieving slimness. However, after the 1970s, Japan experienced a rise in patients with AN who engaged in restriction to achieve thinness. Cases of patients who engaged in binge/purge symptomatology increased after the 1980s, followed by a steady increase in total ED cases after the 1990s. At various time points, providers attributed family conflicts, internalization of a thin ideal of beauty, changing food environments, and pressures associated with traditional gender roles to the onset and maintenance of EDs in Japan.

DISCUSSION

Findings reveal that restrictive EDs were present as early as the 18th century; Japanese patients may present with both "typical" and "atypical" forms of AN; ED symptoms can persist in the absence of Western influence; and sociocultural factors, such as gender-specific stressors and family dynamics, may contribute to EDs for Japanese populations.