TABLE 2 : ARFID Screening Questions of the NIAS 11 1 = Strongly disagree 2 = Disagree 3 = Slightly disagree 4 = Slightly agree 5 = Agree 6 = Strongly agree
Picky Eating I am a picky eater . I dislike most of the foods that other people eat . The list of foods that I like and will eat is shorter than the list of foods I won ’ t eat .
Appetite / Interest I am not very interested in eating ; I seem to have a smaller appetite than other people . I have to push myself to eat regular meals throughout the day or to eat a large enough amount of food at meals . Even when I am eating a food I really like , it is hard for me to eat a large enough volume at meals .
Fear I avoid or put off eating because I am afraid of GI discomfort , choking , or vomiting . I restrict myself to certain foods because I am afraid that other foods will cause GI discomfort , choking , or vomiting . I eat small portions because I am afraid of GI discomfort , choking , or vomiting . ARFID : avoidant-restrictive food intake disorder ; NIAS : Nine Item Avoidant / Restrictive Food Intake Disorder Screen ; GI : gastrointestinal Note . Scores of ≥12 and 24 on the NIAS indicate possible and probable ARFID , respectively .
populations is scarce . However , recent studies suggest over 20 % of adults presenting with GI complaints meet ARFID criteria , 6 , 7 most of whom are female and report fear of the aversive consequences of eating . 6 , 8 Despite this prevalence , providers rarely evaluate patients for ARFID . 6 , 8
Screening for eating and feeding disorders is imperative in primary care settings , especially among patients presenting with GI complaints and unremarkable medical workups . In the case of this patient , her FM physician made the prudent decision to refer her to the specialty clinic .
A patient ’ s body weight may complicate the presentation . Although low weight or weight loss could indicate the presence of a FED , studies show many patients with ARFID have normal or high BMIs . 7 , 9 Furthermore , primary care practitioners may recommend restrictive diets for patients presenting with GI complaints ( e . g ., low fat , small portions ); 10 however , restrictive eating behaviors could initiate or exacerbate GI symptoms . 8 Thus , FED-specific treatment is warranted to ameliorate both psychological and physical symptoms .
A recently developed measure , the Nine Item Avoidant / Restrictive Food Intake
Disorder Screen ( NIAS ), 11 assesses the 3 DSM-5 ARFID symptom patterns ( i . e ., selective eating , lack of interest , fear of aversive consequences ). Items are summed to derive subscale and overall scores . Scores ≥ 12 and 24 indicate possible and probable ARFID , respectively . If screening for ARFID is negative and the patient presents with GI complaints , weight changes and / or elevated eating concerns , screening for other FEDs is warranted . See Table 2 for ARFID screening questions .
CONCLUSIONS
ARFID is a condition in the DSM-5 Feeding and Eating Disorders section that is under-recognized in adults . 9 Patients presenting with GI complaints , selective eating patterns , lack of interest in food , or fear of the aversive consequences of eating should be screened for ARFID and other FEDs . 3 If a FED is suspected , a referral should be made for further evaluation and treatment . Individuals with ARFID are more likely to be seen by primary care than mental health providers given their considerable somatic complaints . 9 Early detection is particularly vital in ARFID , given the high utilization of healthcare , 10 high mortality rates among those with FEDs , 12 and because restrictive eating behaviors can worsen or maintain GI symptoms . 9 Indeed , early detection will not only reduce the substantial public health burden , but also lead to potentially life-saving treatment .
REFERENCES
1 . Rosen E , Sabel AL , Brinton JT , Catanach B , Gaudiani JL , Mehler PS . Liver dysfunction in patients with severe anorexia nervosa . Int J Eat Disord . 2016 ; 49 ( 2 ): 153-160 . doi : 10.1002 / eat . 22436
2 . Disorders A for E . Eating Disorders : A Guide for Medical Care .; 2020 . https :// www . aedweb . org / resources / onlinelibrary / publications / medical-carestandards
3 . Diagnostic and Statistical Manual of Mental Disorders . 5th ed . American Psychiatric Association ; 2013 .
4 . Mangweth-Matzek B , Hoek HW . Epidemiology and treatment of eating disorders in men and women of middle and older age . Curr Opin Psychiatry . 2017 ; 30 ( 6 ): 446-451 . doi : 10.1097 / YCO . 0000000000000356
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