Overview
Avoidant restrictive food intake disorder (ARFID) is an eating disorder in which a person eats a very limited range or amount of food. Unlike anorexia nervosa, it is not driven by concerns about weight or body shape. Instead, food avoidance is linked to sensory sensitivity to taste, texture or smell, fear of unpleasant consequences such as choking, vomiting or pain, or a general lack of interest in food or eating.
ARFID is more than ordinary picky eating. It can lead to weight loss, poor growth in children, nutritional deficiencies, dependence on supplements or tube feeding, and difficulties in social situations involving food. It often begins in childhood and is more common in autistic people and those with anxiety or ADHD, but it can affect people of any age. Treatment focuses on gradually expanding the range and amount of food with psychological and nutritional support.
When to get urgent help
Seek urgent help for fainting, chest pain, very low weight, refusal of all food or fluids, signs of dehydration, or rapid weight loss.
Causes and risk factors
- Sensory sensitivity to textures, tastes, smells or appearance of food
- Frightening experiences such as choking, vomiting, allergic reactions or painful swallowing
- Low appetite or interest in food
- Anxiety disorders
- Autism spectrum disorder
- ADHD
- Gastrointestinal conditions such as reflux or eosinophilic oesophagitis, which can create fear of eating
- Genetic and temperamental factors
How it develops (pathophysiology)
Normal eating behaviour
Eating is controlled by interactions between hunger and fullness signals from the gut and body (hormones such as ghrelin, leptin and insulin), reward circuits in the brain that make food pleasurable, and learned experiences. Most children go through phases of fussiness, but gradually accept a wider range of foods as they are exposed to them repeatedly.
What goes wrong
ARFID develops through different but overlapping pathways:
- Sensory-based avoidance: some people have heightened sensory processing, so certain textures, smells or tastes feel overwhelming or disgusting. They rely on a narrow set of "safe" foods, often with predictable textures and appearance, such as plain carbohydrates or specific brands.
- Fear-based avoidance: after an experience such as choking, the brain's fear learning systems (involving the amygdala) link food with danger. Avoiding feared foods reduces anxiety, which reinforces avoidance through negative reinforcement. Avoidance prevents the person from learning that the food is safe.
- Low interest in eating: some people have weak hunger signals or find eating unrewarding, so they forget to eat or feel full quickly.
Over time, restriction can cause the gut to adapt to small amounts, reinforcing early fullness. Nutritional deficiencies can affect appetite, mood and energy, creating a cycle.
Why the symptoms and effects happen
- Very limited diet reflects reliance on safe foods.
- Weight loss or poor growth results from inadequate energy intake.
- Nutritional deficiencies (iron, vitamins, protein) result from limited variety.
- Anxiety around meals reflects fear conditioning.
- Gagging or vomiting with new foods reflects sensory and fear responses.
- Social difficulties arise from avoiding eating with others.
- Physical effects of malnutrition, such as tiredness, feeling cold, slow heart rate and delayed puberty, reflect low energy intake.
How treatment acts on the mechanism
Cognitive behavioural therapy for ARFID (CBT-AR) uses gradual exposure to new or feared foods, allowing new learning that the foods are safe and tolerable, and reducing avoidance. Food chaining builds from accepted foods to similar new foods. Family-based approaches support children. Dietetic input corrects deficiencies and ensures adequate nutrition. Treating anxiety and underlying gut conditions reduces barriers. Medicines such as low-dose antidepressants or appetite stimulants are used occasionally.
Types
ARFID presentations are often described by main driver, though many people have more than one:
- Sensory sensitivity
- Fear of aversive consequences
- Lack of interest in eating or food
Signs and symptoms
- Eating a very narrow range of foods
- Refusing new foods or entire food groups
- Eating very small amounts
- Weight loss, faltering growth or failure to gain weight in children
- Taking a long time to eat
- Gagging, retching or vomiting with certain foods
- Fear of choking or vomiting
- Anxiety around mealtimes
- Avoiding social events involving food
- Tiredness, feeling cold, dizziness
- Reliance on nutritional supplements or tube feeding
How it is diagnosed
- Assessment by a GP, paediatrician or eating disorder specialist
- Detailed eating history, including foods accepted and reasons for avoidance
- Weight, height and growth charts
- Physical examination, including heart rate and blood pressure
- Blood tests for nutritional deficiencies and complications
- Assessment for co-occurring conditions, such as autism, anxiety or gut disorders
- Distinguishing ARFID from anorexia nervosa and other causes of restricted eating
Possible complications
- Malnutrition and nutritional deficiencies (iron deficiency, vitamin deficiencies, scurvy in rare cases)
- Poor growth and delayed puberty
- Weakened bones
- Heart rhythm problems in severe malnutrition
- Social isolation and anxiety
- Impact on family life
- Dependence on tube feeding
Goals of treatment
Treatment aims to restore adequate nutrition and growth, reduce fear and avoidance, expand the range of foods, and improve quality of life.
Medicines
- Nutritional supplements to correct deficiencies
- Medicines occasionally for anxiety (such as SSRIs) or low appetite (such as cyproheptadine, under specialist advice)
- Treatment of underlying gut conditions
Other treatments
- CBT for ARFID (CBT-AR)
- Family-based treatment for children and teenagers
- Gradual exposure therapy and food chaining
- Dietetic support
- Occupational therapy for sensory difficulties
- Speech and language therapy for swallowing difficulties
- Medical stabilisation or tube feeding in severe malnutrition
Living with it and prevention
- Offer a variety of foods early in childhood without pressure
- Keep mealtimes calm and positive
- Seek help early if a child's eating is very restricted or affecting growth
- Support children after frightening eating experiences such as choking
Monitoring and follow-up
Weight, growth, nutritional status and physical health are monitored regularly. Progress in accepting foods and reducing anxiety is reviewed during therapy.
Outlook
Many people improve with treatment, gradually eating a wider range of foods. Early support leads to better outcomes. Some people continue to have a somewhat limited diet but with adequate nutrition.
Special considerations
- Autistic people: sensory needs should be respected and treatment adapted
- Adults: ARFID is increasingly recognised in adults, who may have lived with it for years
- Infants and toddlers: feeding clinics may be involved
