Gastrointestinal Problems and ARFID

The research on gastrointestinal problems and ARFID shows:

• Abdominal pain and infections are frequent precursors to ARFID in children aged less than 13 years _{(Lieberman et al., 2019)}.

• GI disorders and ARFID have a 19.6%-40% concurrence among paediatric and adult cohorts _{(Harer et al., 2018; Burton Murray et al., 2020; Murray et al., 2021)}. ARFID complicates the clinical presentation of patients in a wide range of GI disorders because diets tend to be low in fibre and lacking vegetables and fruit. This may then exacerbate uncomfortable GI symptoms.

• Nitsch et al (2023), studied 122 ARFID adult patients retrospectively, and observed 41% having DGBI (Disorders of Gut-Brain Interference): 26% presenting with Gastroesophageal Reflux Disease (GORD), 20% experiencing gastroparesis, and 7% with a history of Small Intestinal Bacterial Overgrowth (SIBO). Weeks et al (2023) reviewed disorders of the gut-brain interface (DGBI; functional gastrointestinal disorders) with ARFID and mentioned ‘the possible risk and maintenance pathways between ARFID and DGBI…we offer recommendations for practical treatment management including evidence based diet treatments, treatment risk counseling (sic), and routine diet monitoring’ to reduce the risk of patients developing ARFID.

• Other adult studies using just an ARFID screening tool reported higher levels of suspected ARFID in patients with GI issues. For example, among a cohort of Coeliac patients, Bennett et al (2022) reported 57% patients having suspected ARFID. Fink et al (2022) investigated the levels of ARFID among adults with Achalasia, Celiac Sprue, Eosinophilic Esophagitis and Inflammatory Bowel Disease (IBD) using the Nine Item ARFID Screen (NIAS) _{(Zickgraf & Ellis, 2018)}. They reported ARFID among 53.7% of patients. Fear of GI symptoms, especially with restriction of diet, were present among 80% of patients with achalasia meeting NIAS criteria for ARFID but likely overestimating the prevalence rates of ARFID. In both the above studies, a psychological clinical assessment could have helped to clarify whether the level of patients’ food avoidance exceeded what might have been expected among patients with complex digestive diseases.

• Recent studies suggest that 17% - 32.5% of adult patients with Inflammatory Bowel Disease (IBD) have ARFID _{(Yelencich et al., 2022; Yin et al., 2023)}. Robelin et al (2021) identified that just over 10% of their sample with IBD were also suffering with ARFID - of concern was that clinician sensitivity in identifying an eating disorder was 0%. They suggest that gastroenterologists need training to identify and screen at-risk patients for ARFID and other eating disorders.

• There are, however, concerns that ARFID levels may be overreported owing to overlapping symptomology between ARFID and IBD when only using the NIAS _{(Zickgraf et al., 2018)} as a screening tool to identify suspected ARFID cases.

• However, in clinical practice, it is still likely that ARFID is underdiagnosed and undertreated in IBD _{(Balestrieri et al., 2023)}.

Balestrieri, P., Cicala, M., & Ribolsi, M. (2023). Psychological distress in inflammatory bowel disease. Expert Review of Gastroenterology & Hepatology, 1-15. doi: 10.1080/17474124.2023.2209723

Bennett, A., Bery, A., Esposito, P., Zickgraf, H., & Adams, D. W. (2022). Avoidant/restrictive food intake disorder characteristics and prevalence in adult celiac disease patients. Gastro Hep Advances, 1(3), 321-327. doi: 10.1016/j.gastha.2022.01.002

Burton Murray, H., Jehangir, A., Silvernale, C. J., Kuo, B., & Parkman, H. P. (2020). Avoidant/restrictive food intake disorder symptoms are frequent in patients presenting for symptoms of gastroparesis. Neurogastroenterology & Motility, 32(12), e13931. doi: 10.1111/nmo.13931

Fink, M., Simons, M., Tomasino, K., Pandit, A., & Taft, T. (2022). When is patient behavior indicative of avoidant restrictive food intake disorder (ARFID) vs reasonable response to digestive disease? Clinical Gastroenterology and Hepatology, 20(6), 1241 1250. doi: 10.1016/j.cgh.2021.07.045

Harer, K., Baker, J., Reister, N., Collins, K., Watts, L., Phillips, C., & Chey, W. D. (2018). Avoidant/restrictive food intake disorder in the adult gastroenterology population: an under-recognized diagnosis?: 417. Official Journal of the American College of Gastroenterology, 113(Supplement), S247-S248. doi: 10.14309/00000434-201810001-00417

Lieberman, M., Houser, M. E., Voyer, A. P., Grady, S., & Katzman, D. K. (2019). Children with avoidant/ restrictive food intake disorder and anorexia nervosa in a tertiary care pediatric eating disorder program: A comparative study. International Journal of Eating Disorders, 52(3), 239-245. doi: 10.1002/eat.23027

Murray, H. B., Kuo, B., Eddy, K. T., Breithaupt, L., Becker, K. R., Dreier, M. J., Thomas, J. J., & Staller, K. (2021). Disorders of gut brain interaction common among outpatients with eating disorders including avoidant/restrictive food intake disorder. International Journal of Eating Disorders, 54(6), 952-958. doi: 10.1002/eat.23414

Nitsch, A., Watters, A., Manwaring, J., Bauschka, M., Hebert, M., & Mehler, P. S. (2023). Clinical features of adult patients with avoidant/restrictive food intake disorder presenting for medical stabilization: A descriptive study. International Journal of Eating Disorders, 56(5), 978-990. doi: 10.1002/eat.23897

Robelin, K., Senada, P., Ghoz, H., Sim, L., Lebow, J., Picco, M., & Werlang, M. (2021). Prevalence and clinician recognition of avoidant/restrictive food intake disorder in patients with inflammatory bowel disease. Gastroenterology & Hepatology, 17(11), 510.

Yelencich, E., Truong, E., Widaman, A. M., Pignotti, G., Yang, L., Jeon, Y., & Limketkai, B. N. (2022). Avoid- ant restrictive food intake disorder prevalent among patients with inflammatory bowel disease. Clinical Gastroenterology and Hepatology, 20(6), 1282-1289. doi: 10.1016/j.cgh.2021.08.009

Yin, T., Tu, W., Li, Y., Yang, M., Huang, L., Zhang, S., & Xu, G. (2023). Risk of avoidant/restrictive food intake disorder in patients with inflammatory bowel disease: predictive value of disease phenotype, disease activity and food literacy. Journal of Eating Disorders, 11(1), 211. doi: 10.1186/s40337-023-00936-3

Zickgraf, H. F., & Ellis, J. M. (2018). Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns. Appetite, 123, 32-42. doi: 10.1016/j.appet.2017.11.11