A Guide to Avoidant Restrictive Food Intake

Disorder (ARFID) - Practical tools for the

Psychiatrist Dr. Mark L. Norris, MD, FRCPC

Associate Professor of Pediatrics University of Ottawa

Division of Adolescent Health and Eating Disorders, Children’s Hospital of Eastern Ontario

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Declaration of conflict

Speaker has nothing to disclose with regard to commercial support.

Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.

Funding Disclosures

Research Funding in the last 5 years: • Canadian Institute of Health Research

• Weston Foundation

• Mach Gaensslen Foundation

• Farm Boy

• Bell Let’s Talk

• Public Health Agency of Canada

• CHEO RI

• Hospital for Sick Children

Objectives:

• 1) To provide background information regarding the introduction of ARFID in the DSM-5

• 2) To describe a typical case of ARFID and understand essential points that should be considered in the formulation

• 3) To work through treatment options for patients with ARFID that are guided by diagnostic findings

Objectives:

• 1) To provide background information regarding the introduction of ARFID in the DSM-5

• 2) To describe a typical case of ARFID and understand essential points that should be considered in the formulation

• 3) To work through treatment options for patients with ARFID that are guided by diagnostic findings

DSM-IV to DSM-5

• The goal of the DSM-5 Eating Disorder Working Group

• To make feeding and eating disorders recognizable to non-psychiatrists to facilitate better diagnosis by clinicians

• Adopt a lifespan approach

• To appreciate that symptoms of eating disorders vary according to age and stage of development

• To understand that some types of feeding disturbances seen in young children persist into later childhood, adolescence and adulthood

• To allow for updates and integrating new findings

DSM-IV to DSM-5: Diagnostic

Feeding Disorders of Infancy and

Early Childhood Feeding

and

Eating Disorders

Eating Disorders

DSM – IV Criteria DSM-5 Criteria

Anorexia nervosa - suggested weight cutoffs + amenorrhea ≥ 3 months

Anorexia Nervosa (AN) – amenorrhea & numeric weight cutoffs eliminated; developmental considerations incorporated.

Bulimia Nervosa-binging and purging ≥ 2x/week for ≥ 3 mos.

Bulimia Nervosa (BN) – binging and purging 1x/wk for > 3 mos.

Eating Disorder Not Otherwise Specified included Binge Eating Disorder (BED) in Appendix-binging ≥ 2x week for ≥ 6 mos

Binge Eating Disorder (BED) - binging 1x/ week for 3 mos.

Eating Disorder Not Otherwise Specified Eating Disorders Not Otherwise Specified eliminated

Avoidant/Restrictive Food Intake Disorder (ARFID)

Other Specified Feeding and Eating Disorders

Atypical AN (not underweight)

Purging disorder

Sub-threshold BN (<1x/wk or <3 mos)

Sub-threshold BED (<1x/wk or <3 mos)

Night eating syndrome

Unspecified Feeding and Eating Disorders

Feeding Disorders of Infancy or Early Childhood Feeding Disorders of Infancy or Early Childhood eliminated Avoidant/Restrictive Food Intake Disorder (ARFID) Pica Rumination

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs leading to one or more of the following:

• Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)

• Significant nutritional deficiency

• Dependence on enteral feeding or oral nutritional supplements

• Marked interference with psychosocial functioning

Avoidant/Restrictive Food Intake Disorder (ARFID) – what it is not

• ARFID is NOT the result of lack of available food or an associated culturally sanctioned practice.

• ARFID is NOT associated with any abnormalities in the way in which one perceives their body weight or shape.

• ARFID is NOT explained by another medical or mental disorder, so that if you treat that, the eating problem will go away.

Avoidance or

restriction

Nutritional deficiencies

Weight loss

Alternative feeding

Psychosocial Impairment

No food available

Culturally sanctioned

practice

AN/BN weight, shape concerns

Explained by another condition

Not meeting nutritional needs

Not meeting energy needs

Avoidant/Restrictive Food Intake Disorder of Childhood

Bryant –Waugh, ICED 2014

Objectives:

• 1) To provide background information regarding the introduction of ARFID in the DSM-5

• 2) To describe a typical case of ARFID and understand essential points that should be considered in the formulation

• 3) To work through treatment options for patients with ARFID that are guided by diagnostic findings

•History •Feeding history from birth •When did the issues start? Acute? Acute on chronic? •Persistence of problem •Current food intake •Oral supplement or tube feed dependency •Social/emotional functioning •? Lack of interest in food/ appetite signalling •Sensory profile •Fears/aversion •Family History

•Physical Exam •Weight and height (BMI percentile) •Signs of nutritional deficiency

Key areas to assess when considering ARFID

• Ascertain whether this represents an adequate age-appropriate amount

• is the diet sufficient in terms of overall energy intake?

• Hunger/ Appetite signaling

• Structure at meal times

• Ascertain whether intake is within an adequate age-appropriate range

• does it include major food groups and essential micronutrients?

Current food intake

• Is the individual taking oral nutritional supplements?

• What kinds?

• Traditional vs non-traditional

• Is the individual fed via gastrostomy/ nasogastric tube or other form of enteral feeding?

• Is there dependence on these other methods to ensure sufficient intake?

• Is there a history of dependence on formula/ supplement outside of what would be expected?

Oral supplements/tube feeding

Bryant –Waugh, ICED 2014, with permission

• How long have there been eating difficulties characterized by avoidance or restriction?

• This is to ascertain whether this is a persistent problem rather than a transient one.

Persistence of problem

Bryant –Waugh, ICED 2014, with permission

• Is there evidence of any associated significant distress?

• Is there evidence of associated impairment to the individual’s social and emotional development or functioning?

• In the case of children or younger adolescents, this can include disruptions to normal family function that negatively affect the child.

• How big a deal is this for the patient? For the family?

Social and emotional functioning

Bryant –Waugh, ICED 2014, with permission

More than picky eating

• No standardized definition for “picky eating”

• Consume an inadequate variety of foods

• Limitations in the variety of foods eaten

• Rejection of foods that may either be familiar or unfamiliar to them

• Rejection of foods of a particular texture, consistency, color, or smell

• aberrant eating behaviors

• peaks between the 2nd and 6th year of life, with gradual reduction over time

Food Neophobia

• Unwillingness to try new foods

• Important to ascertain what the exact feeding issues are (as it will impact treatment approach)

Avoidant/Restrictive Food Intake Disorder: A Canadian Paediatric Surveillance Program Study

Principal Investigators Debra Katzman, MD FRCP(C) Hospital for Sick Children and University of Toronto Mark L. Norris, MD FRCP(C) Children’s Hospital of Eastern Ontario and University of Ottawa

Co-investigators

Holly Agostino, MD, McGill University

Jennifer Couturier, MD, MSc, FRCPC, McMaster University

Anna Dominic, MD, FRCPC, Memorial University

Sheri Findlay, MD, FRCPC, McMaster University

Peiyoong Lam, MD, FRACP, University of British Columbia

Margo Lane, MD, FRCPC, University of Manitoba

Danielle Taddeo, MD, Universite de Montreal

Wendy Spettigue, MD, FRCPC, University of Ottawa

Cathleen Steinegger, MD, University of Toronto

Ellie Vyver, MD, FRCPC, University of Calgary

CPSP Surveillance Study and ARFID

• Objectives 1. To determine a conservative incidence rate of ARFID in

children and adolescents in Canada 2. To describe the pathways of referral, patterns of

presentation and clinical features 3. To examine duration of symptom onset prior to

presentation 4. To identify co-morbid psychiatric and medical disorders

that co-occur with ARFID 5. To describe the current treatment planned and/or offered

What is Research Teaching Us?

Cohort Study published July 2014

ARFID: A Descriptive Study (Norris et al. 2014)

• Objective: To assess and compare clinical characteristics of patients with avoidant/restrictive food intake disorder (ARFID) to those with anorexia nervosa (AN).

• Methods:

• Two hundred and five patients reviewed in detail.

• 34 (5%) patients met criteria for ARFID

• matched sample of 36 patients with AN

ARFID: A Descriptive Study (Norris et al. 2014)

• Results

• Most common criteria observed in the ARFID group was “significant weight loss (or failure to gain weight or faltering growth in children)” found in 32/34 (94%)

• Eating pathology consisted of food avoidance (based upon sensory issues relating to food texture, smell, general dislike of food(s), and/ or underlying non-ED related fears) in 31/34 (91%)

ARFID: A Descriptive Study (Norris et al. 2014)

• Most common symptoms associated with ARFID • abdominal pain (35.3%) • fear of vomiting (26.5%) • generalized anxiety with

eating (20.6%) • complaints of feeling full

(20.6%) • nausea (17.6%) • unpleasant sensory

experiences associated with eating (17.6%)

ARFID: A Descriptive Study (Norris et al. 2014)

• 24% (n=8) with ARFID required admission (or had already been hospitalized) at the time the first assessment occurred

• A significantly greater proportion of patients in the AN were hospitalized (53%, n=19, p= 0.031) at or immediately after assessment.

ARFID: A Descriptive Study (Norris et al. 2014)

• Triage route

• 24% of patients meeting criteria for ARFID presented to the gastro-intestinal subspecialty service before being referred to the ED program.

• 29% of patients presented to the ED as a result of concerns by parents resulting from the feeding difficulty.

A New DSM-5 Diagnosis (Fisher et al, 2014)

• Methods

• retrospective case-control study of 8-18 year-olds

• seven adolescent medicine eating disorder programs in 2010

• using a diagnostic algorithm compared all cases of ARFID to a randomly selected sample of patients with anorexia nervosa and bulimia nervosa

A New DSM-5 Diagnosis (Fisher et al, 2014)

• Results

• At six of the seven sites, the frequency of patients with ARFID ranged between 7.2% and 17.4%

• 28.7% with selective (picky) eating since early childhood

• 4.1% with food allergies

December 2014

Predictors of Outcome at 1 Year: QI Collaborative (Forman et al , 2016)

• Purpose • Analyze demographics of diagnostic categories

and predictors of weight restoration at 1 year • Methods

• Retrospective review of 700 adolescents aged 9-21 years

• 14 Adolescent Medicine Eating Disorder Programs

Predictors of Outcome at 1 Year: QI Collaborative (Forman et al , 2016)

• One-year follow-up defined as the appointment between 9 and 15 months closest to the 1-year mark from intake.

• Of the 700 intakes

• 383 individuals (54.7%) had follow-up data at a 1-year visit

• 241 (34.4%) were <90% mBMI at intake

Addressing confounders…..

Results

Predictors of Outcome at 1 Year: QI Collaborative (Forman et al , 2016)

Results

• ARFID patients were

• significantly younger (p < .0001)

• had longer duration of illness before presentation (p < .04)

• less likely to have followed up over 1 year (p < .02)

• Compared with ARFID paitents

• Those with atypical AN had a four-time higher odds of weight recovery

• Those with AN had a two-time higher odds of weight recovery

December 2015

ARFID: Illness and Hospital Course (

Stranjord et al, 2015)

• Retrospective chart review of hospitalized ARFID and AN patients between 2008 and 2014

• Hospitalized for acute medical stabilization at an academic medical center.

• Characteristics on admission, during hospitalization, and 1 year after discharge were recorded for AN and ARFID patients

ARFID: Illness and Hospital Course (

Stranjord et al, 2015)

Results

• ARFID patients relied on more enteral nutrition and required longer hospitalizations than AN patients (8 vs. 5 days; p<.0006)

• One year after discharge, ~ 50% of ARFID and AN patients met criteria for remission (62% vs. 46%; p<.18),

• ¼ required readmission (21% vs. 24%;p<.65)

What can one anticipate with an admission?

Objectives:

• 1) To provide background information regarding the introduction of ARFID in the DSM-5

• 2) To describe a typical case of ARFID and understand essential points that should be considered in the formulation

• 3) To work through treatment options for patients with ARFID that are guided by diagnostic findings

What about treatment approaches?

• Norris et al. (presented AED 2016, currently unpublished)

• Potpourri of medications prescribed

• 42% of our patients treated with at least one medication

Treatment Approaches/ Requirements

• At the time of last clinical encounter or discharge from care, only 40% (n=19) were weight restored

• 40% of cases received Family-Based Therapy (n=19), of which n=9 (47%) became weight restored.

• Follow-up care with other sub-specialty medical clinics and mental health teams was required in 48% (n=23) and 31% (n=15) of cases, respectively.

Norris et al. (presented AED 2016, currently unpublished)

Where does all of this leave us?

• Some prevailing trends

• Some inconsistencies (length of impairment/ symptoms for example)

• It has become clear that ARFID is an UMBRELLA term.

• The question at this stage – can we do better?

Building Evidence for the Use of Descriptive Subtypes in Youth with Avoidant Restrictive Food

Intake Disorder

“ARFID-avoidant”

• Restriction based upon Nutritional Avoidance/ Fear of Adverse Consequences:

• Patients with histories of nutritional avoidance/ restriction, which occur and/or evolve as a result of a specific anxiety, event, or fear (e.g. fear of pain or nausea).

“ARFID-aversive”

• Restriction based upon Nutritional Aversions:

• Patients with histories of longstanding feeding issues (e.g. food neophobia and/ or picky eating), sensory and/or texture issues, aversions related to food items, and/or profound rigidity involving the act of eating (e.g. food items on a plate cannot touch).

“ARFID-limited intake”

• Weight loss, medical compromise, and/ or impairment as a consequence of insufficient caloric intake relating to: low overall appetite (or lack of interest); factors related to the act of feeding; or excessive energy demands.

• Important factors noted in the histories of patients in this subtype include relative energy deficiency that manifests by either weight loss, inadequate weight gain for growth, growth stunting; feeding-specific issues (e.g. small bite sizes, prolonged duration to finish meals, etc.), or excessive energy expenditure.

Summary

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