Psychometric properties of an Arabic translation of the Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) in a community sample of adults

BACKGROUND

No epidemiological data is yet available on Avoidant/Restrictive Food Intake Disorder (ARFID) in Arab countries, which may in part be due to the lack of measures available in Arabic language. This constitutes a major obstacle to further progress of our understanding of the nature, aetiology, course, treatment, and prevention of ARFID, especially as some evidence suggested that ARFID may vary across cultures and food environments. We aimed to contribute to the literature in the eating disorders field by examining the psychometric properties of an Arabic translation of the Nine Item ARFID Screen (NIAS).

METHOD

This was a cross-sectional, web-based study. A total of 515 Lebanese community adults (mean age of 27.55 ± 10.92 years, 69.9% females) participated. The forward-backward method was adopted to translate the NIAS from English to Arabic.

RESULTS

Confirmatory Factor Analyses provided evidence for the adequate fit indices for the three-factor model (i.e., Picky eating, Fear, and Appetite) and the 9-item version of the NIAS. An adequate reliability of the Arabic NIAS was achieved, with McDonald's ω ranging from .75 to .90 for the total score and all three subscores. Multi-group analyses demonstrated measurement invariance by sex (males vs. females) and weight groups (underweight/healthy weight [BMI ≤ 25] vs. overweight/obese [BMI > 25]) at the configural, metric, and scalar levels. Adequate patterns of correlations between the NIAS and measures of disordered eating symptoms, psychological distress and well-being were seen. In particular, fear was significantly associated with non-ARFID disordered eating symptoms. Appetite and Picky eating, but not Fear, were inversely correlated with well-being. All three NIAS subscores and the total score were positively correlated with psychological distress.

CONCLUSION

Findings provided evidence that the Arabic NIAS is a short, valid and reliable self-report measure to screen for ARFID symptoms. In light of these findings, we recommend its use for clinical and research purposes among Arabic-speaking adults.

A Systematic Review to Manage Avoidant/Restrictive Food Intake Disorders in Pediatric Gastroenterological Practice

Avoidant/Restrictive food intake disorder (ARFID) is a feeding disorder characterized by persistent difficulty eating, such as limited choices of preferred foods, avoidance or restriction of certain foods or food groups, and negative emotions related to eating or meals. Although ARFID mainly affects children, it can also occur in adolescents and adults. ARFID can have serious physical and mental health consequences, including stunted growth, nutritional deficiencies, anxiety, and other psychiatric comorbidities. Despite its increasing importance, ARFID is relatively underrecognized and undertreated in clinical practice. Treatment consists of a multidisciplinary approach involving pediatric gastroenterologists, nutritionists, neuropsychiatrists, and psychologists. However, there are several gaps in the therapeutic approach for this condition, mainly due to the lack of interventional trials and the methodological variability of existing studies. Few studies have explored the nutritional management of ARFID, and no standardized guidelines exist to date. We performed a systematic literature review to describe the different nutritional interventions for children and adolescents diagnosed with ARFID and to assess their efficacy and tolerability. We identified seven retrospective cohort studies where patients with various eating and feeding disorders, including ARFID, underwent nutritional rehabilitation in hospital settings. In all studies, similar outcomes emerged in terms of efficacy and tolerability. According to our findings, the oral route should be the preferred way to start the refeeding protocol, and the enteral route should be generally considered a last resort for non-compliant patients or in cases of clinical instability. The initial caloric intake may be adapted to the initial nutritional status, but more aggressive refeeding regimens appear to be well tolerated and not associated with an increased risk of clinical refeeding syndrome (RS). In severely malnourished patients, however, phosphorus or magnesium supplementation may be considered to prevent the risk of electrolyte imbalance, or RS.

Avoidant Restrictive Food Intake Disorder: A Narrative Review of Types and Characteristics of Therapeutic Interventions

The diagnosis of avoidant/restrictive food intake disorder (ARFID) was added to the diagnostic and statistical manual of mental disorders (DSM-5) just 10 years ago. This disorder consists of the failure to meet one's nutritional and/or energy needs, which may result in significant weight loss, significant nutritional deficit or functioning dependent on enteral nutrition or oral supplements. In children with this disorder, development is often problematic, and there is also marked interference with psychosocial functioning at all ages. The causes leading to food avoidance in these patients may be related to a lack of interest, to the sensory properties of the food or to the possible adverse consequences associated with it. Given the multitude of aspects involved in this disorder and the impact it has especially on younger patients, more and more studies are addressing treatments and related benefits and/or complications. A narrative review of currently published studies was performed for articles published before 5 March 2023 on therapeutic interventions in patients with ARFID. Because of the large number of results obtained, this review was conducted only via PubMed in order to analyze and discuss children and adolescent ARFID treatments reported in literature. The treatments most often referred to in the literature are cognitive behavioral therapy, family-based therapy and pharmacological treatment. All the data on these treatments are promising. However, due to the recent introduction of this disorder and the limited data still available, a multidisciplinary approach seems to be the best option.

Systematic Review of the Incidence and/or Prevalence of Eating Disorders in Individuals With Food Allergies

BACKGROUND

Chronic diseases involving strict dietary adherence have been associated with an increased risk of eating disorders (EDs). This is the first systematic review investigating the rate of EDs among individuals with food allergies (FAs).

OBJECTIVE

To report the incidence, prevalence, and types of EDs in individuals with FAs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases for studies published to January 2022 that reported the prevalence or incidence of EDs in samples with immunoglobulin E (IgE) or non-IgE-mediated allergy. Risk of bias was assessed and evidence qualitatively synthesized.

RESULTS

From 1,180 papers identified, 9 met inclusion criteria. There were 4,161 adult and pediatric participants with IgE-mediated FAs or eosinophilic esophagitis. Avoidant/Restrictive Food Intake Disorder (ARFID) or anorexia nervosa/bulimia nervosa were the main EDs identified. The prevalence of EDs in samples with FA ranged from 0.8% to 62.9%. Among studies investigating IgE-mediated FA (n = 6), the prevalence of anorexia nervosa and/or bulimia nervosa ranged from 17.6 to 61%, ARFID was 62.9%, and unspecified EDs was 0.8% to 6%. Among samples with eosinophilic esophagitis (n = 3), ARFID prevalence ranged from 4.5% to 51%. Most studies were limited by small sample size, possible selection bias, and lack of diagnostic EDs tools validated for food allergic populations.

CONCLUSIONS

Eating disorders appear prevalent in individuals with FA; however, prevalence estimates varied widely. Large studies with healthy control groups and validated measures to identify EDs in individuals with FA are needed to accurately determine the prevalence of EDs.

Low bone mineral density is found in low weight female youth with avoidant/restrictive food intake disorder and associated with higher PYY levels

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is a restrictive eating disorder commonly associated with medical complications of undernutrition and low weight. In adolescence, a critical time for bone accrual, the impact of ARFID on bone health is uncertain. We aimed to study bone health in low-weight females with ARFID, as well as the association between peptide YY (PYY), an anorexigenic hormone with a role in regulation of bone metabolism, and bone mineral density (BMD) in these individuals. We hypothesized that BMD would be lower in low-weight females with ARFID than healthy controls (HC), and that PYY levels would be negatively associated with BMD.

METHODS

We performed a cross-sectional study in 14 adolescent low-weight females with ARFID and 20 HC 10-23 years old. We assessed BMD (total body, total body less head and lumbar spine) using dual x-ray absorptiometry (DXA) and assessed fasting total PYY concentration in blood.

RESULTS

Total body BMD Z-scores were significantly lower in ARFID than in HC (- 1.41 ± 0.28 vs. - 0.50 ± 0.25, p = 0.021). Mean PYY levels trended higher in ARFID vs. HC (98.18 ± 13.55 pg/ml vs. 71.40 ± 5.61 pg/ml, p = 0.055). In multivariate analysis within the ARFID group, PYY was negatively associated with lumbar BMD adjusted for age (β = -0.481, p = 0.032).

CONCLUSION

Our findings suggest that female adolescents with low-weight ARFID may have lower BMD than healthy controls and that higher PYY levels may be associated with lower BMD at some, but not all, sites in ARFID. Further research with larger samples will be important to investigate whether high PYY drives bone loss in ARFID.

Risk Factors Related to Eating Disorders in a Romanian Children Population

(1) Background: The complex known as avoidant/restrictive food intake disorder (ARFID) is one of the eating disorders that cannot be explained by chronic disease. The aim of this study was to determine the characteristics of patients who were identified as being at risk of developing ARFID and referred to paediatricians, according to their age and duration of symptoms. (2) Methods: Children aged 2-10 years (Group 1) presenting with eating disorders were initially recruited in the "Dr. Victor Gomoiu" Clinical Children Hospital in Bucharest. Group 2 included patients presenting for routine paediatric visits as controls. The study population was given the PARDI questionnaire as well as questions related to demographics, screening growth and development, physical and mental background, and current feeding and eating patterns. Items were scored on a 7-point scale ranging from 0 to 6. (3) Results: A total of 98 individuals were divided equally into the two study groups. There was no difference in terms of sex, living area, mothers' education level or living standards between the two groups. ARFID children were more likely to be underweight, were unsuccessful at weaning or have irregular feeding habits and a history of allergies. The mean age of onset for chronic symptoms was significantly lower than the onset of acute food refusal-4.24 ± 2.29 vs. 6.25 ± 3.65, p = 0.005. (4) Conclusions: feeding disorders are an important issue among paediatricians, and a proper awareness of them when treating these patients should be included in daily practice.

Current evidence for avoidant restrictive food intake disorder: Implications for clinical practice and future directions

Background

ARFID (avoidant restrictive food intake disorder) is a relatively new diagnostic term covering a number of well-recognised, clinically significant disturbances in eating behaviour unrelated to body weight/shape concerns. Its phenotypic heterogeneity combined with much about the condition remaining unknown, can contribute to uncertainties about best practice. While other reviews of the evidence base for ARFID exist, few specifically target health care professionals and implications for clinical practice.

Methods

A narrative review was conducted to synthesise the findings of ARFID papers in scientific journals focussing on four key areas relevant to clinical practice: prevalence, assessment and characterisation of clinical presentations, treatment, and service delivery. Freely available online databases were searched for case studies and series, research reports, review articles, and meta-analyses. Findings were reviewed and practice implications considered, resulting in proposed clinical recommendations and future research directions.

Results

We discuss what is currently known about the four key areas included in this review. Based on available evidence as well as gaps identified in the literature, recommendations for clinical practice are derived and practice-related research priorities are proposed for each of the four of the areas explored.

Conclusion

Prevalence studies highlight the need for referral and care pathways to be embedded across a range of health care services. While research into ARFID is increasing, further studies across all areas of ARFID are required and there remains a pressing need for guidance on systematic assessment, evidence-based management, and optimal service delivery models. Informed clinical practice is currently predominantly reliant on expert consensus and small-scale studies, with ongoing routine clinical data capture, robust treatment trials and evaluation of clinical pathways all required. Despite this, a number a positive practice points emerge.

A Survey of Community Providers on Feeding Problems in Autism Spectrum Disorder

PURPOSE

Feeding problems, ranging from mild to severe, are common in children with autism spectrum disorder. We conducted a 15-item online survey of community providers to gather information on service demand and current treatment approaches for this clinical population.

METHODS

Respondents, speech-language pathologists, occupational therapists, registered dietitians, and Board-Certified Behavior Analysts, were recruited via e-mail listservs, professional conferences, continuing education programs, social media and electronic newsletters. The survey included questions about professional discipline, years in practice, patient population served, feeding problem types, therapeutic approaches, and level of interest in parent-mediated interventions.

RESULTS

A total of 541 community practitioners responded to the survey; 419 provided usable data. Across all providers, 97% (n = 406) reported seeing children with ASD and feeding problems. Of these, 90% (n = 367) offered treatment. Providers (n = 23) who did not treat feeding problems cited "insufficient training." Most common presenting problems included limited dietary variety, texture sensitivity, and disruptive mealtime behavior. Although treatment approaches varied across disciplines, 89.3% indicated openness to parent-mediated treatment.

CONCLUSIONS

These results indicate a high demand for treatment of children with ASD and feeding problems across disciplines. Food selectivity was the most common problem. Treatment approaches varied across disciplines. Dissemination and implementation of evidence-based, parent-mediated intervention is warranted.

Scurvy, abnormal MRI, and gelatinous bone marrow in an adolescent with avoidant restrictive food intake disorder

BACKGROUND

Although medical literature describes pediatric scurvy as "rare", a growing number of case reports suggests otherwise. Patients often undergo costly and unnecessary workup due to unfamiliarity with the presentation of scurvy. This case report further supports the small yet growing literature documenting scurvy and its manifestations in patients with eating disorders.

CASE PRESENTATION

A 15-year-old female presented to the emergency department with bilateral knee and ankle swelling and pain in the setting of chronic lower limb rash and BMI of 16.3. For years, she had restricted her diet to carbohydrates. Exam showed perifollicular petechial hemorrhagic rash with corkscrew hairs, knee edema, ankle edema with restricted range of motion, and antalgic gait. She was admitted for severe malnutrition from avoidant restrictive food intake disorder. Her hospital course was complicated by recurrent normocytic anemia and fever. Hematology workup revealed anemia from iron deficiency, vitamin K deficiency, and anemia of chronic disease. Rheumatology workup was negative. MRI findings showed dark T1 and bright T2 signals and were read as consistent with leukemia/lymphoma, chronic multifocal osteomyelitis, or Langerhans cell histiocytosis. However, bone marrow biopsy showed gelatinous transformation secondary to malnutrition. She was treated with vitamin C and a nutrition plan and her symptoms improved.

CONCLUSIONS

Although this patient had common manifestations of scurvy, including perifollicular petechial hemorrhagic rash, joint effusions, anemia, and recurrent fevers, she still underwent an extensive workup. Clinicians should be aware that scurvy can present with multiple symptoms that mimic infectious, rheumatic, oncologic and hematological disease. Clinicians should have a high index of suspicion for scurvy in patients with malnutrition and eating disorders.

What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) was a new diagnosis in DSM-5. This systematic review explores what is known to date about the epidemiology of ARFID in children and adolescents.

METHOD

Embase, Medline and PsycInfo were used to identify studies meeting inclusion criteria. PRISMA guidelines were followed.

RESULTS

Thirty studies met inclusion criteria, with most coming from specialised eating disorder services where prevalence rates were 5%-22.5%. Three studies from specialist feeding clinics showed the highest prevalence rates, ranging from 32% to 64%. Studies from non-clinical samples reported ARFID prevalence estimates ranging from 0.3% to 15.5%. One study, using national surveillance methodology, reported the incidence of ARFID in children and adolescents reaching clinical care to be 2.02 per 100,000 patients. Psychiatric comorbidity was common, especially anxiety disorders (9.1%-72%) and autism spectrum disorder (8.2%-54.75%).

CONCLUSION

The current literature on the epidemiology of ARFID in children and adolescents is limited. Studies are heterogeneous with regard to setting and sample characteristics, with a wide range of prevalence estimates. Further studies, especially using surveillance methodology, will help to better understand the nature of this disorder and estimate clinical service needs.

Development of a brief cognitive-behavioral treatment for avoidant/restrictive food intake disorder in the context of disorders of gut-brain interaction: Initial feasibility, acceptability, and clinical outcomes

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) symptoms are common (up to 40%) among adults with disorders of gut-brain interaction (DGBI), but treatments for this population (DGBI + ARFID) have yet to be evaluated. We aimed to identify initial feasibility, acceptability, and clinical effects of an exposure-based cognitive-behavioral treatment (CBT) for adults with DGBI + ARFID.

METHODS

Patients (N = 14) received CBT as part of routine care in an outpatient gastroenterology clinic. A two-part investigation of the CBT included a retrospective evaluation of patients who were offered a flexible (8-10) session length and an observational prospective study of patients who were offered eight sessions. Feasibility benchmarks were ≥75% completion of sessions, quantitative measures (for treatment completers), and qualitative interviews. Acceptability was assessed with a benchmark of ≥70% patients reporting a posttreatment satisfaction scores ≥3 on 1-4 scale and with posttreatment qualitative interviews. Mixed model analysis explored signals of improvement in clinical outcomes.

RESULTS

All feasibility and acceptability benchmarks were achieved (and qualitative feedback revealed high satisfaction with the treatment and outcomes). There were improvements in clinical outcomes across treatment (all p's < .0001) with large effects for ARFID fear (-52%; Hedge's g = 1.5; 95% CI = 0.6, 2.5) and gastrointestinal-specific anxiety (-42%; Hedge's g = 1.0; 95% CI = 0.5, 16). Among those who needed to gain weight (n = 10), 94%-103% of expected weight gain goals were achieved.

DISCUSSION

Initial development and testing of a brief 8-session CBT protocol for DGBI + ARFID showed high feasibility, acceptability, and promising clinical improvements. Findings will inform an NIH Stage 1B randomized control trial.

PUBLIC SIGNIFICANCE

While cognitive-behavioral treatments (CBTs) for ARFID have been created in outpatient feeding and eating disorder clinics, they have yet to be developed and refined for other clinic settings or populations. In line with the recommendations for behavioral treatment development, we conducted a two-part investigation of an exposure-based CBT for a patient population with high rates of ARFID-adults with disorders of gut-brain interaction (also known as functional gastrointestinal disorders). We found patients had high satisfaction with treatment and there were promising improvements for both gastrointestinal and ARFID outcomes. The refined treatment includes eight sessions delivered by a behavioral health care provider and the findings reported in this article will be studied next in an NIH Stage 1B randomized controlled trial.

A proposed trumping scheme for other specified feeding or eating disorder: Comment on Walsh et al., 2023

The recent systematic review by Walsh, Hagan, & Lockwood (Int J Eat Disord, in press) highlights the importance of further distinguishing atypical anorexia nervosa (atypical AN) from other feeding and eating disorders. The lack of a trumping scheme within other specified feeding or eating disorder (OSFED) hinders intervention selection in the clinical context and reduces reliability of diagnostic classification in research samples. Thus, we propose a trumping scheme within OSFED that mirrors the existing diagnostic algorithm in the main DSM-5-TR feeding and eating disorders section. According to this scheme, a diagnosis of atypical AN would override all other OSFED subcategories. Subthreshold bulimia nervosa (BN) would trump subthreshold binge-eating disorder (BED) and purging disorder; purging disorder would trump subthreshold BED and night eating syndrome; night eating syndrome would trump subthreshold BED; and subthreshold BED would trump subthreshold avoidant/restrictive food intake disorder (ARFID)-a novel presentation that we propose adding under the OSFED umbrella to parallel the existing subthreshold classifications for the main feeding and eating disorders. We hope this proposed OSFED trumping scheme will improve intervention selection and diagnostic reliability in clinical and research contexts, and serve as a catalyst for future research on these newly recognized-but common and impairing-feeding and eating disorder presentations.

Assessment and Treatment of Avoidant/Restrictive Food Intake Disorder

PURPOSE OF REVIEW

To review the literature pertaining to the assessment and treatment of avoidant/restrictive food intake disorder (ARFID) ten years following its introduction to DSM-5.

RECENT FINDINGS

Several structured clinical interviews for assessing ARFID have been developed, each with its own strengths and limitations. There is no clear leading self-report measure for tracking treatment progress and outcome in ARFID. Medical assessment is comprised of examining anthropometrics, vitamin deficiencies, and other comorbidities. To date, several studies have reported on cognitive behavioral therapy, family-based treatment, and other approaches to the treatment of ARFID. These treatments appear promising; however, they rely on data from clinical case series and very small randomized controlled trials. Several promising assessments and treatments for ARFID are in the early stages of research. Yet, controversies remain. These include (a) overlap with criteria for pediatric feeding disorder; (b) the optimal method for assessing nutrient deficiencies; (c) disciplines involved in treatment. Future research innovation is necessary to improve the psychometric properties of ARFID assessments and evaluate treatment efficacy with larger samples and randomized designs.

Clinical features of adult patients with avoidant/restrictive food intake disorder presenting for medical stabilization: A descriptive study

OBJECTIVE

The purpose of this study is to describe the clinical features of adult patients with avoidant/restrictive food intake disorder (ARFID) to better understand the medical findings, psychological comorbidities, and laboratory abnormalities in this population.

METHOD

We completed a retrospective chart review of all adult patients with a diagnosis of ARFID, admitted for medical stabilization, between April 2016 and June 2021, to an inpatient hospital unit, which specializes in severe eating disorders. Information collected included anthropomorphic data, laboratory assessments, and medical history at time of admission.

RESULTS

One hundred and twenty-two adult patients with ARFID were identified as meeting inclusion criteria for the study. The most common ARFID presentation was "fear of adverse consequences." The majority were female (70%), with an average age of 32.7 ± 13.7 years and mean percent of ideal body weight (m%IBW) of 68.2 ± 10.9. The most common laboratory abnormalities were low serum prealbumin and vitamin D, hypokalemia, leukopenia, and elevated serum bicarbonate. The most common psychiatric diagnoses were anxiety and depressive disorders, and the most common medical diagnoses were disorders of gut-brain interaction (DGBI).

DISCUSSION

This is the largest study to the authors' knowledge of medical presentations in adult patients with ARFID. Our results reflect that the adult patient with ARFID may, in some aspects, present differently than pediatric and adolescent patients with ARFID, or from ARFID patients requiring less intensive care. This study highlights the need for further investigation of adult patients with ARFID.

PUBLIC SIGNIFICANCE

ARFID is a restrictive eating disorder first defined in 2013. This study explores the medical presentations of adult patients (>18 years old) with ARFID presenting for specialized eating disorder treatment and identifies unique features of the adult presentation for treatment, compared to pediatric and adolescent peers.

Linear growth in young people with restrictive eating disorders: "Inching" toward consensus

Background

While the assessment of acute medical stability in patients with eating disorders should never be minimized, careful attention toward other specific age-related consequences of malnutrition can improve psychological outcomes and reduce long-term, potentially irreversible medical complications, like linear growth impairment.

Review

While the impact of malnutrition on linear growth is widely recognized, emerging data highlight consensus in several key areas: the time from onset to time of diagnosis, age at illness onset, pubertal stage at illness onset, and adequacy of weight restoration to achieve catch-up growth. This review provides concrete and actionable steps to help providers identify and explore deviations in expected growth and development while prioritizing early and aggressive weight restoration to provide the best opportunity for catch-up linear growth in patients with eating disorders.

Conclusion

The impact of restrictive eating disorders on growth and development cannot be overstated, particularly in pre- and peripubertal patients. While many consequences of malnutrition are reversible, the loss of genetic height potential may prove irreversible without early and aggressive weight restoration.

Feeding/Eating problems in children: Who does (not) benefit after behavior therapy? A retrospective chart review

Background

Treating disordered feeding at a young age reduces risks of future feeding problems, but not all children profit equally; can we define predictors of a worse prognosis?

Objectives

In 252 children, with a mean age of 4; 7 years (SD = 3 years; range 5 months to 17; 10 years), who had undergone behavioral day treatment in the past, several variables were investigated, retrieved from initial consultation (t1) and re-assessed at follow-up (t2).

Method

Logistic regressions were carried out with sex, gastro-intestinal problems, refusal of the first nutrition, syndrome/intellectual disability, Down's syndrome, autism spectrum disorder, comorbidity of medical diseases (other than gastro-intestinal problems), restrictive caloric food intake and selective food intake, as the predictor variables from t1, and age-appropriate food intake at t2 as the dependent variable. The potential role of sensory processing problems was reviewed at t2.

Results

About 73% had improved towards an age-appropriate food intake. Sex (boys), syndrome/intellectual disability, and a lack of varied nutritional intake at t1 were predictors of a worse prognosis. We found a small, but significant correlation between current selective eating patterns and general sensory processing problems.

Conclusion

Feeding disordered children, especially boys, with intellectual disabilities or selective eating patterns are at risk for not achieving an age-adequate food intake at a later age, despite behavioral treatment.

Exploration of Treatment Response in Parent Training for Children with Autism Spectrum Disorder and Moderate Food Selectivity

Managing Eating Aversions and Limited Variety (MEAL) Plan is a structured parent-mediated intervention for children with autism spectrum disorder and moderate food selectivity. Our previously reported group-based clinical trial revealed a positive treatment response rate of 47.3%. Although encouraging, this response rate raises questions about factors that may affect treatment outcomes. Here, we examine the impact of child and parent characteristics and feeding behaviors on treatment response. Higher maternal education and higher child communication abilities at baseline were associated with positive treatment response. Improvement in sitting at the table and reductions in disruptive mealtime behavior promoted treatment success. Results also suggest that individually delivered MEAL Plan may offer more flexibility than group-based intervention for some parents.

Suspicion of Munchausen syndrome by proxy with a child's presentation of undernutrition, scurvy, and an apparent Avoidant Restrictive Food Intake Disorder

PURPOSE

Avoidant Restrictive Food Intake Disorder (ARFID) was recently characterized in the DSM-5 classification. Potential differential diagnoses remain poorly reported in the literature. Our purpose was to present a possible Munchausen syndrome by proxy with undernutrition and scurvy, presenting as ARFID in a child.

METHODS

We describe here a case of an 8-year-old boy who presented with severe undernutrition (BMI = 11.4) and scurvy leading to joint pains. The boy had had a very selective diet since early childhood, and his condition required hospitalization and enteral refeeding. Because of his specific eating behaviour, an ARFID was initially suspected. However, observation of the mother-child relationship, analysis of the child's eating behaviour, and retrospective analysis of his personal history suggested that this was not a true ARFID, and that the selective eating behaviour had probably been induced by the mother over many years, who probably maintained a low variety diet.

CONCLUSION

Munchausen syndrome by proxy is a difficult differential diagnosis, which may also affect patients with ARFID symptoms, which may also present in the affected child as apparent ARFID.

LEVEL OF EVIDENCE

Level V, descriptive study.

Validation study on the child, adult, and parent version of the ARFID module 2.0 for the Eating Disorder Examination

OBJECTIVE

This study presents a psychometric evaluation of the avoidant/restrictive food intake disorder (ARFID) module 2.0 for the Eating Disorder Examination (EDE), its child (ChEDE), and parent version. Within a pediatric sample seeking treatment for restrictive feeding or eating disorders and non-treatment-seeking controls, the module's interrater reliability, parent-child agreement, and its convergent, divergent, and discriminant validity were examined.

METHOD

The child, adult, and/or parent version of the German ARFID module was administered to N = 176 children and adolescents (0-17 years) and their parents, as were the (Ch)EDE, well-established measures on food-avoidance behaviors, food variety, and body esteem, and objective anthropometric measures.

RESULTS

Across all versions of the ARFID module, substantial to almost perfect interrater reliability was shown. Parent-child agreement for ARFID diagnosis was substantial. Based on medium-to-large associations between interview-assessed avoidant/restrictive food intake and questionnaire-assessed food-avoidance behaviors, food variety, and objective weight status, the module showed high convergent validity, especially for the child and parent version. Low associations of avoidant/restrictive food intake with weight and shape concern demonstrated divergent validity. Individuals with ARFID differed significantly from those with anorexia nervosa and individually matched controls in a range of clinical characteristics, indicating discriminant validity.

DISCUSSION

This comprehensive validation supports the EDE ARFID module to be a valuable measure for the assessment and diagnosis of ARFID in 0-17-year-olds based on self- and parent-report. Validation of the ARFID module against other interview-based measures on ARFID and its evaluation in an adult sample are pending.

PUBLIC SIGNIFICANCE

Based on good reliability and validity of the avoidant/restrictive food intake disorder (ARFID) module for the Eating Disorder Examination (EDE) in its child, adult, and parent version, the present study paves the way for the clinical and research use of the interview-based EDE ARFID module for assessing ARFID across childhood and adolescence.

Case report: Pulmonary hypertensive crisis leading to cardiac arrest during endoscopic evaluation in a 6-year-old boy with autism, severe malnutrition, and undiagnosed scurvy

Pediatric gastroenterologists are often responsible for the evaluation of malnutrition in the setting of selective eating. Endoscopic evaluation for conditions including eosinophilic esophagitis and celiac disease can help to identify and treat mucosal disease contributing to food selectivity. However, undiagnosed micronutrient deficiencies can cause cardiovascular derangements that significantly increase a patient's anesthetic risk. Vitamin C deficiency in particular, alone or in combination with severe malnutrition, is associated with a severe but reversible form of pulmonary arterial hypertension that, while life threatening in the acute phase, may significantly improve within days of starting ascorbic acid replacement therapy. Here we present a case of a 6-year-old boy with autism spectrum disorder (ASD), severe malnutrition, and undiagnosed chronic vitamin C deficiency who developed a pulmonary hypertensive crisis after induction of general anesthesia leading to cardiac arrest during endoscopic evaluation. While the association between food selectivity among youth with neurodevelopmental differences and vitamin C deficiency is well-described, and pulmonary hypertension is a recognized rare complication of scurvy, extant literature has not addressed next steps to improve patient outcomes. Using this case report as a foundation, we discuss specific patient populations to screen and treat for micronutrient deficiencies prior to anesthesia and propose a novel clinical algorithm for pre-anesthesia risk stratification and mitigation in patients specifically at risk for scurvy and associated pulmonary hypertension.

Cross-cultural adaptation and validation of the Nine Item ARFID Screen (NIAS) in Mexican youths

Avoidant/Restrictive Food Intake Disorder (ARFID) is defined by limited volume or variety of food intake motivated by the sensory properties of food, fear of aversive consequences, or lack of interest in food or eating associated with medical, nutritional, and psychosocial impairment. Currently, two of the most widely validated measures are The Eating Disturbances in Youth-Questionnaire (EDY-Q) and the Nine Item ARFID Screen (NIAS). The latter has proven valid and reliable for assessing this disorder.

OBJECTIVE

To validate a culturally sensitive adaptation of the NIAS instrument and evaluate its psychometric properties in Mexican youths.

METHOD

The sample consisted of 800 participants aged 12-30 (M = 18.56, SD = 3.52) from Mexico City and Hidalgo public educational institutions.

RESULTS

The S-NIAS obtained a Cronbach's alpha of 0.84, adequate construct validity adjustment rates: CMIN = 1.88; GFI = 0.97; AGFI = 0.94; CFI = 0.98; RMR = 0.050; and RMSEA = 0.047. Measurement invariance by gender, age, and survey administration which show that construct is understood in the same way across both groups and despite the change from paper-and-pencil to online survey administration.

CONCLUSION

The psychometric properties of the Spanish Nine Item ARFID Screen (S-NIAS) indicate that it is a valid and reliable instrument for evaluating symptoms associated with ARFID in this sample of youths.

PUBLIC SIGNIFICANCE

Although there are advances in studying ARFID, their epidemiological data comes mainly from a few countries. Furthermore, these data are scarcer due to the lack of validated screening and assessment instruments available in a variety of world languages; having instruments for the evaluation of ARFID symptoms is essential because it could function as an auxiliary means for the detection and prevention of people at risk.

Neurobiology of Avoidant/Restrictive Food Intake Disorder in Youth with Overweight/Obesity Versus Healthy Weight

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) occurs across the weight spectrum, however research addressing the coexistesnce of ARFID with overweight/obesity (OV/OB) is lacking. We aimed to establish co-occurrence of OV/OB and ARFID and to characterize divergent neurobiological features of ARFID by weight.

METHOD

Youth with full/subthreshold ARFID (12 with healthy weight [HW], 11 with OV/OB) underwent fasting brain fMRI scan while viewing food/non-food images (M age = 16.92 years, 65% female, 87% white). We compared groups on BOLD response to high-calorie foods (HCF) (vs. objects) in food cue processing regions of interest. Following fMRI scanning, we evaluated subjective hunger pre- vs. post-meal. We used a mediation model to explore the association between BMI, brain activation, and hunger.

RESULTS

Participants with ARFID and OV/OB demonstrated significant hyperactivation in response to HCF (vs. objects) in the orbitofrontal cortex (OFC) and anterior insula compared with HW participants with ARFID. Mediation analysis yielded a significant indirect effect of group (HW vs. OV/OB) on hunger via OFC activation (effect = 18.39, SE = 11.27, 95% CI [-45.09, -3.00]), suggesting that OFC activation mediates differences in hunger between ARFID participants with HW and OV/OB.

CONCLUSIONS

Compared to youth with ARFID and HW, those with OV/OB demonstrate hyperactivation of brain areas critical for the reward value of food cues. Postprandial changes in subjective hunger depend on BMI and are mediated by OFC activation to food cues. Whether these neurobiological differences contribute to selective hyperphagia in ARFID presenting with OV/OB and represent potential treatment targets is an important area for future investigation.

Food neophobia as a mechanism of change in video-delivered cognitive-behavioral therapy for avoidant/restrictive food intake disorder: A case study

OBJECTIVE

The mechanisms through which cognitive-behavioral therapies (CBTs) for avoidant/restrictive food intake disorder (ARFID) may work have yet to be elucidated. To inform future treatment revisions to increase parsimony and potency of CBT for ARFID (CBT-AR), we evaluated change in food neophobia during CBT-AR treatment of a sensory sensitivity ARFID presentation via a single case study.

METHOD

An adolescent male completed 21, twice-weekly sessions of CBT-AR via live video delivery. From pre- to mid- to post-treatment and at 2-month follow-up, we calculated percent change in food neophobia and ARFID symptom severity measures. Via visual inspection, we explored trajectories of week-by-week food neophobia in relation to clinical improvements (e.g., when the patient incorporated foods into daily life).

RESULTS

By post-treatment, the patient achieved reductions across food neophobia (45%), and ARFID severity (53-57%) measures and no longer met criteria for ARFID, with sustained improvement at 2-month follow-up. Via visual inspection of week-by-week food neophobia trajectories, we identified that decreases occurred after mid-treatment and were associated with incorporation of a food directly tied to the patient's main treatment motivation.

DISCUSSION

This study provides hypothesis-generating findings on candidate CBT-AR mechanisms, showing that changes in food neophobia were related to food exposures most connected to the patient's treatment motivations.

PUBLIC SIGNIFICANCE

Cognitive-behavioral therapies (CBTs) can be effective for treating avoidant/restrictive food intake disorder (ARFID). However, we do not yet have evidence to show how they work. This report of a single patient shows that willingness to try new foods (i.e., food neophobia), changed the most when the patient experienced a clinical improvement most relevant to his motivation for seeking treatment.

A comparison of the eating disorder service experiences of autistic and non-autistic women in the UK

Objective

Qualitative studies report that autistic women have poor experiences when being treated for an eating disorder (ED) and express that ED services are not appropriately tailored to meet their needs. It is unclear whether their experience differs to other women accessing ED services. The aim of the current study was to compare autistic and non‐autistic women's ED illness history and experiences in ED services.

Method

An online survey about ED illness history and their experience with ED treatment was completed by 46 autistic women with a restrictive ED and 110 non‐autistic women with a restrictive ED.

Results

Despite some similarities, there were three key differences in the experiences reported by autistic and non‐autistic women. First, autistic women reported a longer duration of ED and being diagnosed with an ED at a younger age than non‐autistic women. Second, autistic women reported accessing a broader range of healthcare settings and ED treatments than non‐autistic women when being treated for an ED. Finally, autistic women rated their experiences of inpatient care, dietetic input, and cognitive behavioural therapy (CBT) as significantly less beneficial than non‐autistic women when being treated for an ED.

Conclusion

These findings increase understanding of autistic women's ED experience and can help to shape ED services and treatments to better accommodate the needs of their autistic clients.

The current study is the first to compare the eating disorder (ED) illness history and treatment experiences of autistic and non‐autistic women.

Autistic women with EDs are diagnosed at a younger age and report longer illness duration than non‐autistic women.

Autistic women with EDs tend to access a broader range of healthcare settings and ED treatments than non‐autistic women, but report these to be less beneficial.

Delayed avoidant restrictive food intake disorder diagnosis leading to Ogilvie's syndrome in an adolescent

PURPOSE

Avoidant restrictive food intake disorder (ARFID) was recently characterized, according to the DSM-5 classification, as a feeding and eating disorder (FED). However, ARFID remains poorly known by most pediatricians, but also by psychiatrists and primary care professionals. Despite the fact that patients with ARFID generally have a higher BMI than patients with anorexia nervosa, our purpose was to highlight the fact that they may present severe nutritional deficiencies and major somatic complications when the diagnosis is delayed.

METHOD

We describe here a case of a 16-year-old boy who presented with severe undernutrition (BMI = 11.5) leading to Ogilvie's syndrome, which resolved with enteral refeeding. Because of undernutrition, very bad dental condition, and encopresis, some physicians wrongly suspected child neglect, but retrospective analysis of his personal history revealed a long-term FED and sensory specificities that led to the final diagnosis of an ARFID-autism spectrum disorder (ASD) association. A literature review was conducted on the ARFID somatic complications.

CONCLUSION

The training of health professionals in the clinical forms of pediatric FED, including ARFID, is necessary, to promote early diagnosis and prevent poor nutritional outcomes. In this case the association of ARFID-ASD and the delay in access to specialized care favored by the disadvantaged social environment led to severe gastrointestinal complications.

LEVEL OF EVIDENCE

V, descriptive study.