This position statement was created by a specially convened working group including dietitians with expertise in this area.
Published date: June 2022
Renewal date: June 2024
Avoidant/Restrictive Food Intake Disorder (ARFID) was introduced as a new mental health and behaviour disorder diagnosis in 2013. ARFID is characterised by a pattern of eating that avoids certain foods or food groups entirely and/or eating small amounts due to lack of interest in food, high sensitivity to sensory aspects of food (such as texture, colour, or taste), and/or fear of aversive consequences such as being sick or choking. These restrictive eating patterns can result in significant health problems. It differs from other eating disorders in that people with ARFID do not restrict their food intake for the specific purpose of losing weight or managing feelings of fear and anxiety around their shape and size.
Dietitians with specialist training are essential for the management of ARFID from the point of assessment and diagnosis and throughout treatment. When dietitians are not embedded within a team and dietetic time is not adequately resourced, there is likely to be nutritional and dietary compromise of patients1,2. This will impact on their physical health and wellbeing, psychosocial functioning, quality of life, growth and may lengthen treatment of the patient with ARFID3. In turn this is likely to have cost implications, impact the rest of the team and affect patient care if the patient deteriorates further in health.
Services are currently being developed for CYP with ARFID throughout the UK. Funding to support adequate dietetic time in ARFID services is essential and this paper aims to identify what the BDA considers is adequate and why. Misdiagnosing and underdiagnosing ARFID has serious implications for patient care, and it requires specialist and multidisciplinary assessment and care pathways4. This position paper highlights the importance of early identification of nutritional deficit and management and the important role of dietitians.
Professor Waller (2019) comments that ARFID is "old wine in a new bottle" with a clear definition, description of the problem, identification, and intervention. Clinically, many dietitians agree that this is not a new problem, but a new definition and we have the skills, experience, and expertise to work with these patients.
Across hospitals and health providers in the UK conversations are starting about ARFID services. This position paper is written by dietitians for dietitians, clinicians, commissioners, and service users to influence and support their position with those who provide and commission services for CYP with ARFID. This paper will help to raise awareness that dietitians are central to the assessment and treatment of these patients. When a team is adequately resourced with dietetic time, the contributions of the dietitian are invaluable to children, young people, their families as well as the team as a whole.1-3,5,6
ARFID Awareness UK, on behalf of parents/carers and individuals with ARFID says:
Dr Rosan Meyer says: "The risk of not employing a specialist dietitian with knowledge on working with ARFID as part of a multidisciplinary team managing patients with ARFID may therefore lead to provision of inappropriate dietary advice, which may do more psychological and/or physical harm by not recognising that patients with this diagnosis require unique sensory, psychological and nutritional management strategies."
The BDA emphasises in this position paper that there is limited research on the role and efficacy on all clinicians in ARFID, not just dietitians. Research is developing continuously, and it is hoped that this will include the role of the dietitian in ARFID.
ARFID is an eating disorder, newly categorised as a diagnosis in DSM-5 in 2013, but previously referred to by different names such as selective eating disorder, fussy eating, feeding disorder, picky eating, feeding disorder of infancy and early childhood7. Dietitians have been seeing patients with forms of restricted eating (some now known to have met the criteria for ARFID) for many years in a variety of settings including paediatrics, community child and adolescent mental health services (CAMHS), and adult services, such as gastroenterology and community.
Many Trusts and Health Boards do not have a dedicated clinical pathway or service for providing assessment and treatment to children, young people (YP) or adults with ARFID. Referrals for ARFID present in multiple services but as they do not fit ‘criteria’ and/or are unable to access clinical expertise they fall between the gaps. The clinical expertise is not present within any one service to meet the complex needs of this group of children. There are no evidence / practice guidelines which clearly describe the service specifications and clinical pathway required to manage this population.
Pathways need to be created locally to determine appropriate multi-disciplinary assessment and treatment for CYP with ARFID. This has major implication for funding/resourcing of dietetic time within services and specifically many CAMHS and CYP Eating Disorders Services and paediatrics where these patients are currently being signposted.
ARFID is a feeding disorder manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with at least one of the following criteria: significant nutritional deficiency, significant weight loss or failure to gain adequate weight, dependence on oral supplementation or tube feeding, and/or marked interference with psychosocial functioning. Avoidant restrictive feeding behaviours may arise because of poor tolerance of specific sensory-related aspects of food, fear of adverse consequences of feeding, and/or an overall lack of interest in food or feeding as classified in World Health Organization International Classification of Diseases, 11th Revision (ICD-11) definitions.8
Angharad Banner: Highly Specialist Paediatric & CAMHS Dietitian at Cwm Taf Morgannwg Health Board. Freelance Dietitian & Public Relations Officer of the Paediatric Specialist Group of the BDA.
Paola Falcoski: Advanced Specialist Eating Disorder Dietitian, Bedfordshire & Luton CAMHS Eating Disorders Team. Freelance Dietitian.
Claire Knight: Clinical Lead Dietitian for Nottingham Child & Adolescent Eating Disorder Service. Chair of the BDA Specialist Interest Group for CAMHS. Project Lead NHS England ARFID Pilot Study for the Midlands Region 2019/2020.
Dr Elizabeth Roberts: Advanced Specialist Eating Disorders Dietitian, Somerset NHS Foundation Trust.
Michelle Simpson: Lead Specialist Paediatric Eating Disorders Dietitian, Hampshire CAMHS Eating Disorders Team.
Sian Taylor: Clinical Lead Dietitian & Operations Manager, CAMHS, Aneurin Bevan Health Board. Chair of the ARFID All Age Specialist Interest Group (ARFID SIG).
Clare Thornton-Wood: Paediatric Dietitian - Clinical Dietetic Lead Feeding and Eating Disorders at Great Ormond Street Hospital for Children NHS Foundation Trust. BDA Media Spokesperson.
Mala Watts: Specialist Paediatric Eating Disorder Dietitian, Buckinghamshire Eating Disorder Service, Oxford Health NHS Foundation Trust. Education Lead ARFID SIG. Freelance Dietitian.
This position paper has been written by members of the ARFID Special Interest Group (ARFID SIG). The ARFID SIG is part of the British Dietetic Association (BDA) CAMHS sub-group of the Mental Health SIG. The authors collaborated with members of the Paediatric Specialist Group. ARFID Awareness UK (AAUK) were also consulted (AAUK) to include the voice of patients and carers.
The need for a position paper came about from the recognition of ARFID as an eating disorder in both the DSM-5 criteria and ICD11 in 2013 and 2022 respectively. This position paper has focused on Children and Young People (CYP).
A group of dedicated and highly specialist dietitians in eating disorders and paediatrics UK wide convened. The draft was circulated to specialist ARFID colleagues including paediatricians, psychologists, and dietitians.
Our acknowledgements go to Glenn Waller, Rosan Meyer, Luise Marino, Rachel Bryant-Waugh, Damien Wood, Gillian Harris, Susan Meredith and ARFID Awareness UK.