A R F ID

When It’s Not Just

“Picky Eating”
Carly Onopa, RDN, LDN, CEDS
Devoted Recovery

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A g e nd a
I. What is Avoidant Restrictive Food Intake Disorder (ARFID)?

I. Neurodivergence & ARFID

I. Dietary Approaches for ARFID

I. Summary

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M eet G
16 year old, White, cis-gender, heterosexual female presenting for outpatient care.
At initial intake, Mom reports that she has “always been a picky eater,” has “weird food
combinations” and is losing “safe foods”
● Growth charts demonstrate that she has not gained weight in the past year,
causing her to fall off her growth curve
● G shared that at meal time she experiences dread and anxiety, especially when
trying new foods
● Dietary assessment indicates low protein and fruit intake, no vegetable
consumption
● Physical symptoms: difficulty sleeping, headache, cold intolerance, fatigue,
decreased appetite; labs indicate iron deficiency anemia
Mom shares that there is meal time drama among G and siblings

This is an example of ARFID.

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What is ARFID?
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Avoidant Restrictive Food Intake Disorder (ARFID)
Involves limiting the amount and/or types of foods consumed due to:

● Sensory characteristics of food

● Fear of bad things happening if they eat a particular food (i.e., gagging,
throwing up, etc)
● Lack of interest in food

**Restriction is not due to body concerns and is not better explained by

another circumstance or diagnosed condition**

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ARFID Statistics
ARFID is a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th
edition. At this time, these statistics are preliminary.

ARFID is observed in young children, but is not a child’s illness. Of those diagnosed with ARFID,

● 20% say they avoid foods because of sensory issues

● 50% say they have a fear of vomiting or choking
● 33% are diagnosed with a mood disorder
● 75% are diagnosed with an anxiety disorder
● 20% are diagnosed with Autism Spectrum**

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Do I have ARFID?
Do you have a limited number of accepted foods (<10)?

Do you avoid entire food groups (protein, fruits, vegetables)?

Do you have difficulty trying new foods?

Have you unintentionally lost weight recently or have difficulty maintaining your growth/weight?

Does your relationship with food impact your ability to do daily activities?

Do you have signs of a nutrient deficiency?

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Neurodivergence & ARFID

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**A note on Neurodivergence
Neurodiversity: “refers to the virtually infinite variability of human cognition and the
uniqueness of each human mind” - term coined by Judy Singer
● Judy Singer stated that “Neurodiversity is:
○ a state of nature to be respected
○ an analytical tool for examining social issues
○ an argument for the conservation and facilitation of human diversity”
○ It is NOT a diagnosis

Neurodivergent: umbrella term for individuals who have a mind/brain that diverges
from what is “typical.” - Kassiane Asasumasu
● Kassiane Asasumasu stated that “this is not a term for exclusion but
rather inclusion.”

A neurodivergent person may experience ARFID. ARFID can also be considered a form of
neurodivergence on its own.
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Le t’s Che ck in on G
G is diagnosed with:

● ARFID
● ADHD
● Anxiety
● Depression

ARFID, ADHD, Anxiety and Depression can all change the way a person thinks and
experiences the world. These are all forms of neurodivergence.

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Why talk about Neurodivergence?
In addition to living in a fatphobic world, we also live in an ableist world.

A neurodivergent person may experience microaggressions in the form of:

● Being told that their way is “weird”
● Coerced to do things in a “normative” way
● Overlooked because of their unique way of doing something
● Lack of accommodations to help them be successful
AND MANY MORE….

These microaggressions add up and impact a neurodivergent person’s

experience in accessing care and implementing strategies.
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Dietary Approaches for
ARFID
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Dietary Approaches for ARFID
Dietary approaches for ARFID should be:

1. Individualized

1. Accommodating & Strengths Based

1. Supporting, Not Fixing

Oftentimes, clients are in a state of fight or

flight, so calming the body and mind is a
top priority!
“Sympathetic And Parasympathetic Nervous System Stock Illustration. .”
IStock Photo, 25 Oct. 2019. Accessed 13 Mar. 2023. 13
Dietary Approaches for ARFID
Clients with an ARFID diagnosis are unique and therefore have
unique concerns.

Things to consider:

1. Current weight versus weight history

2. Current food patterns and how it has changed over time
3. Co-occurring conditions
4. Eating Environment
5. Coping strategies

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Dietary Approaches for ARFID: Weight Restoration
Low energy intake or inadequate nutrient intake can negatively impact a client’s
growth, development and overall health.

When this is the case:

1. Determine their individualized target weight using their own personal weight
history and growth charts (if available)
2. Work towards nutritional adequacy, focusing on accepted foods and
accommodating eating environment!
3. Discuss use of a multivitamin to address low vitamin and mineral intake

Malnutrition can increase fight-flight response. Increasing overall

energy intake can be calming.
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Dietary Approaches for ARFID: Accepted Foods
Accepted foods may stay the same for clients, but they also may decrease
over time.

Questions to ask:
1. What are foods that you are able to eat more easily (accepted foods)?
2. What are foods that you used to eat but recently stopped eating?
3. What are foods that you can eat sometimes but can’t other times?
4. Are there foods you want to try?

Clients should feel comfortable eating foods that match their preference without
judgment. We can teach them to advocate for their needs without shame.
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Dietary Approaches for ARFID: Note on New Foods
Not all ARFID clients will progress to adding new foods and this is OKAY! Food preferences
are allowed and accepted.

When someone expresses interest in trying new foods, using a “rubber band” approach (also
called food chaining) can be helpful
● Ex: Tyson’s brand chicken nugget (accepted food) → different brand chicken nugget
→ grilled chicken “nuggets” → grilled chicken breast

Trying new foods can increase fight-flight response and should only be done when a
client’s body and brain is more nourished.

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Dietary Approaches for ARFID: Co-Occurring Conditions
Co-occurring conditions are critical to keep in mind when treating any eating
disorder. Co-occurring conditions may change:

● Treatment approach or members on the treatment team

● Interventions
● Support system

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Dietary Approaches for ARFID: Eating Environment
Food is already distressing for many ARFID clients.

Important to ask:
● What is your meal time like?
● What would make your meal time less stressful/more enjoyable?

From there, we try to create an eating environment that helps a client regulate by
having lighthearted conversation and incorporating coping skills.

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Dietary Approaches for ARFID: Coping Strategies
Coping, or calming, strategies are unique
to each person. There isn’t one right way
to cope.

As a dietitian, I help my clients find coping

skills for before, during and after a meal.

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 Nutrition therapy was not target to make her

G’s Nutrition Therapy eating “normal”. Nutrition therapy was focused

on reducing stress at meal times, improving iron
status, increasing acceptance of her favorite
G works with a treatment team that includes: foods, and improving her growth
and development.
● Pediatrician
● Dietitian (me!)
● Therapist
● Psychiatrist

Start by LISTENING to G’s and Mom’s concerns. Dietary concerns: stressful meal times, lack of growth in past 1 year,
decreasing number of accepted foods

Next, Therapist and Dietitian work together on calming strategies to reduce fight-flight response

Then, Dietitian talks with Mom about a positive meal time environment for her and all kids, which includes G having access to
accepted foods if she doesn’t like what’s being served. G increases her energy intake through use of accepted foods only. G
starts taking a multivitamin, specifically iron and vitamin C to help with anemia*

When weight is mostly restored, G then expresses interest in having a food that she used to eat. Dietitian and G try this
food in an appointment and work to integrate this into her eating pattern.**

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In Summary
Clients with an ARFID diagnosis are unique and therefore have unique concerns. This can
span from concerns about growth to eating in front of friends or more.

Nutrition therapy for ARFID should be individualized, accommodating, strengths-based, and

supportive. Calming the body and mind is a good place to start with treatment.

Nutrition therapy is not about fixing our patients, but addressing their individual
concerns and teaching them to advocate for their nutritional needs and food preferences
without shame.

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Questions?
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