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How Drew School Can Create an Environment That Promotes ARFID Recovery
As for all eating disorders:
- Create an environment in which health is not defined in such definitive terms
-Unhelpful comments or qualifications about certain kinds of foods is not conducive to a person with ARFID who is maybe struggling with shame or otherness.
- What is healthy for YOU might not be healthy for somebody else
- Be mindful about how you talk about participation in school sports or weight/diet talk
Avena, N. M., & Bocarsly, M. E. (2012). Dysregulation of brain reward systems in eating disorders: neurochemical information from animal models of binge eating, bulimia nervosa, and anorexia nervosa. Neuropharmacology, 63(1), 87–96. https://doi.org/10.1016/j.neuropharm.2011.11.010
As ARFID is significantly under-researched, there are very little scientific sources that analyze how ARFID works in the brain.
A 2023 study through the Journal of Eating Disorders found that people with ARFID experience a lack of anticipatory and consumatory pleasure around food. This was measured using a diagnostic interview and a self-report Temporal Experience of Pleasure scale. Within the ARFID sample, individuals with more severe ARFID reported less anticipatory pleasure, even after removing questions about enjoyment of food.
The American Psychological Association defines ARFID as “(a)n eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs", associated with one or more of the following:
-Weight issues (loss or failure to achieve expected weight gain)
- Dependence on nutritional supplements
- Significant intereference with psychosocial functioning
Establishing support networks for individuals and families affected by ARFID
This presentation was extremely hard to research for, let alone find a study for, even though ARFID patients may account for up to 20% of individuals seeking eating disorder treatment (according to the National Library of Medicine).
Autism or sensory issues are a huge contributing factor, as ARFID is often caused by sensory discomfort towards certain foods.
In 2023, researchers at Karolinska Institutet and the University of North Carolina School of Medicine did a study investigating genetic factors in developing ARFID. A cohort of almost 17,000 pairs of twins in Sweden born between 1992 and 2010 participated in the study. They discovered that the genetic component for developing ARFID was extremely high - 79%, suggesting that ARFID is very heritable.
Another important factor to note is trauma. Oftentimes traumatic events related to food, such as choking or a difficult surgery, can result in the development of ARFID.
The Children's Hospital of Eastern Ontario Research Institute records the case of Jason, "a 10-year-old boy who was not a picky eater at all, until he nearly choked on a hot dog eight months ago.
The hot dog dislodged and he did not require medical attention immediately after the incident; however, since that day Jason has been reluctant to eat out of fear of choking.”
Bibliography:
- Eating disturbance (restriction, avoidance, aversion)
- Physical health complications (significant weight loss or nutritional deficiencies, interference with psychosocial functioning)
Some comorbidities include anxiety, autism, and ADHD - according to the National Eating Disorders Collaboration, it is estimated that 21% of people with autism experience ARFID in their lifetime.
JJ, T., & EA, L. (2024, February). Avoidant/restrictive food intake disorder (ARFID). Avoidant/Restrictive Food Intake disorder (ARFID). https://nedc.com.au/eating-disorders/types/arfid#:~:text=The%20most%20common%20conditions%20that,in%20their%20lifetime%20(7)
Kim, Y. K., Di Martino, J. M., Nicholas, J., Rivera-Cancel, A., Wildes, J. E., Marcus, M. D., Sapiro, G., & Zucker, N. (2022). Parent strategies for expanding food variety: Reflections of 19,239 adults with symptoms of Avoidant/Restrictive Food Intake Disorder. International Journal of Eating Disorders, 55(1), 108-119. https://doi.org/10.1002/eat.23639
Children's Hospital of Eastern Ontario Research Institute. (2015, June 18). Avoidant/restrictive food intake disorder: More than just picky eating. ScienceDaily. Retrieved March 9, 2024 from www.sciencedaily.com/releases/2015/06/150618073222.htm
Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Current pediatrics reports, 6(2), 107–113. https://doi.org/10.1007/s40124-018-0162-y
Dolan, S.C., Kambanis, P.E., Stern, C.M. et al. Anticipatory and consummatory pleasure in avoidant/restrictive food intake disorder. J Eat Disord 11, 198 (2023). https://doi.org/10.1186/s40337-023-00921-w
Steward, T., Menchon, J. M., Jiménez-Murcia, S., Soriano-Mas, C., & Fernandez-Aranda, F. (2018). Neural Network Alterations Across Eating Disorders: A Narrative Review of fMRI Studies. Current neuropharmacology, 16(8), 1150–1163. https://doi.org/10.2174/1570159X15666171017111532
Scharner, S., & Stengel, A. (2019, February 13). Alterations of brain structure and functions in anorexia nervosa. Clinical Nutrition Experimental. https://www.sciencedirect.com/science/article/pii/S2352939318300484#sec4
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Sanchez-Cerezo, J., Nagularaj, L., Gledhill, J., & Nicholls, D. (2023). What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature. European eating disorders review : the journal of the Eating Disorders Association, 31(2), 226–246. https://doi.org/10.1002/erv.2964
Van Buuren, L., Fleming, C.A.K., Hay, P. et al. The prevalence and burden of avoidant/restrictive food intake disorder (ARFID) in a general adolescent population. J Eat Disord 11, 104 (2023). https://doi.org/10.1186/s40337-023-00831-x
Hughes, T. (2023, February 1). Serious eating disorder Arfid is highly heritable, according to New Twin Study. Newsroom. https://news.unchealthcare.org/2023/02/serious-eating-disorder-arfid-is-highly-heritable-according-to-new-twin-study/#:~:text=Dr.,are%20explained%20by%20genetic%20factors
”Etiology of the broad avoidant restrictive food intake disorder phenotype in Swedish twins aged 6 to 12 years”, Lisa Dinkler, Marie-Louis Wronski, Paul Lichtenstein, Sebastian Lundström, Henrik Larsson, Nadia Micali, Mark J. Taylor, Cynthia M. Bulik, JAMA Psychiatry, online 1 February 2023, doi: 10.1001/jamapsychiatry.2022.4612
Strategies to promote recovery and well-being in individuals with ARFID
- Participants thought encouraging and understanding parenting strategies were more helpful in expanding food variety and increasng pleasure around eating.
- "From these findings, the researchers concluded that creating a positive emotional context surrounding food and eating with others" may help promote ARFID recovery.
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-This suggests that a residential or group therapy facility might be effective in ARFID treatment.
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- Caused by a concurrent medical condition (i.e gastrointestinal issues)
- Caused by lack of access to food
- Caused by any body or weight image issues, and does not occur exclusively during anorexia or bulimia nervosa (important to note that they can occur concurrently)
Cingulate Cortex
As malnutrition and nutritional deficiencies are part of an ARFID diagnosis, one can use fMRI scans of patients with other eating disorders to understand how malnutrition might affect brain functioning.
A narrative review completed by the National Library of Medicine in 2018 found that most commonly malnourishment leads to loss of grey and white matter in the brain (which leads to impairment of memory, motor skills, and decision making).
Restrictive eating disorders have been noted to create increased activity in the amygdala and the cingulate cortex (linked to reward and punishment information)
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The role of family in supporting individuals with ARFID
- Treatment, like that for all eating disorders, can range from an outpatient multidisciplinary team (medical doctor, dietician, therapist, psychiatrist) to inpatient medical hospitalization
- "Volume before variety"
- A 2018 study published in the Current Pediatrics Report recommended Cognitive Behavioral Therapy (CBT) as the standard practice made up of four stages - "1) psychoeducation and regular eating; (2) re-nourishment and treatment planning; (3) addressing relevant maintaining mechanisms ; (4) preventing relapse." For individuals still living with their parents, family involvement is highly recommended.
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- In a 2022 study, researchers at Duke University asked a group of 19,232 adults who identified as "picky eaters" (both adults with and without diagnosed ARFID were included) to "reflect on their parents’ feeding strategies when they were children to better understand which strategies were perceived as helpful and which weren’t."
- Participants thought feeding strategies seen as "coercive" were unhelpful - being forced to eat something, parents becoming angry due to food avoidance, or not being allowed to leave the table until a meal was completed.
The most common misconception is that ARFID is just picky eating, and that it's not a "real eating disorder".
"Dylan" struggles with thoughts of “this isn’t really an illness, I’m choosing this. Why can't I just try it?", even though it isn't that straight forward.
They experience guilt about "safe foods" (foods they can always eat without being scared of getting sick), and how expensive their's tends to be, as well as the financial burden their eating disorder puts on their family.
For "Dylan", ARFID treatment has mostly been about challenging specific fear foods and physical discomfort around fullness (drinking a lot of water to expand stomach, logging challenge foods). There is very little psychological treatment, such as cognitive behavioral therapy or learning coping skills.
"Dylan" finds the lack of resources available about ARFID very challenging, especially when it comes to misconceptions about ARFID.
An collection of animal models on eating disorder hormonal disregulation assembled by the National Library of Medicine found that malnourishment caused by anorexia nervosa created a decrease in serotonin and dopamine.
Based on these findings, one can infer that malnourishment prompted by ARFID would generate similar hormonal deficiencies.
"Dylan" is a 17-year-old ARFID patient who was officially diagnosed in September 2023.
"Dylan" believes they were born with ARFID, as ever since they were young, they have been highly selective about eating based on smell, texture, or fear of food being undercooked.
As a result of ARFID, "Dylan" experienced dramatic weight loss that, reinforced by positive reactions towards the weight loss, resulted in a now concurrent anorexia diagnosis.
"Dylan" experiences severe anxiety around trying new foods which results in lack of adequate nutrition due to the highly selective food range
Family relationships have become stressful for them as their parents struggle with knowing how to help them due to shortage of information on ARFID. Socially, they feel isolated - they can't make decisions on where to eat, and going to someone's house for meals can be super stressful.
They also have to miss out on a lot of hobbies that involve physical activity due to the fragility of their physical health.