Avoidant Restrictive Food Intake Disorder (ARFID)
The symptoms are defined by ICD-11, and relate to avoidance or restriction of food intake that results in either or both of the following:
- The intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements that has resulted in significant weight loss, clinically significant nutritional deficiencies, dependence on oral nutritional supplements or tube feeding, or has otherwise negatively affected the physical health of the individual.
- Significant impairment in personal, family, social, educational, occupational or other important areas of functioning (e.g. due to avoidance or distress related to participating in social experiences involving eating).
The pattern of eating behaviour is not motivated by preoccupation with body weight or shape.
Restricted food intake and consequent weight loss (or failure to gain weight), or other impact on physical health or related functional impairment, are:
- not due to unavailability of food;
- not a manifestation of another medical condition (e.g. food allergies, hyperthyroidism) or mental disorder;
- not due to the effects of a substance or medication, including withdrawal effects.
Typical reasons for food avoidance in ARFID are:
- Lack of appetite
- Fear of adverse consequences of eating
- Difficulties with particular sensory experiences (e.g. taste, texture etc).
PLEASE SEE ‘HOW TO REFER’ (BELOW) FOR RED FLAG INDICATIONS FOR URGENT REFERRAL.
For the Lothian Eating Disorder Service (LEDS) to consider an ARFID referral, there needs to be some evidence of either nutritional insufficiency or significant functional impairment in line with the diagnostic criteria above.
If there is doubt about this, the Short ARFID Screen – Clinician (SAS-C) may be helpful.
LEDS is available to liaise with other clinicians or services when a patient has disordered eating for psychological reasons but does not have a traditional eating disorder (where concerns about body shape or weight are prominent features).
Please note the initial management of those with possible ARFID and:
- Poor appetite – which is associated with numerous physical and mental health conditions. Management of comorbidities should be optimised before seeking ARFID assessment.
- Food avoidance – which is often identified as being a response to specific physical symptoms that would typically be associated with gastrointestinal conditions. Where this is the case, and the symptoms are not resolving with primary care management, patients should first be referred to GI for assessment. Examples include:
- Nausea and / or vomiting
- Abdominal pain or discomfort
- Bloating
- Diarrhoea
- Constipation.
Who can refer:
ARFID referrals are accepted from GPs, Community Mental Health Teams, or other medical or mental health professionals.
Where a patient is already known to a mental health service, referral should come from that service.
Who to refer:
Patients where ARFID is being considered as a diagnosis and where related physical co-morbidities and GI symptoms have been assessed (see above).
Who not to refer:
Patients with a primary personality disorder or addiction or severe mental health problem who may also have ARFID should initially be referred to general adult or addiction services for assessment.
How to refer:
Referrals should be via SCI Gateway. If there is no access to SCI Gateway, please send a referral letter to The Cullen Centre, Tipperlinn House, Tipperlinn Road, Royal Edinburgh Hospital, EH10 5HF.
Referral Checklist:
Please note if the answer to any of these 5 questions is ‘Yes’, mark the referral as URGENT.
- BMI 15 or under
- BMI under 18.5 and rate of weight loss is 1kg per week or greater
- Pregnant
- Insulin Dependent Diabetes Mellitus
- Medical complications as a result of eating disorder
- Co-morbid alcohol or drug dependence
| Please specify medical complications. | |
| Please detail any psychiatric co-morbidities | |
| Pulse and BP are helpful | |
| Mandatory information: | Height Weight BMI Date measured Does the patient give permission for us to contact them by phone? |
| Required baseline blood tests taken within a month of referral date: | Full Blood Count Vitamin B12 and folate Urea and Electrolytes Liver Function Tests Thyroid Function Tests Calcium & Phosphate Magnesium Glucose Creatinine Kinase |
Please see Referral Guidelines for more detail:
Undertake the initial physical assessments and tests (see how to refer).
Consider physical co-morbidities which may be contributing to food restriction or avoidance, or caused by them
Refer to gastroenterology where ongoing GI symptoms in conjunction with poor appetite may indicate physical pathology
ARFID SCREENING
The Short ARFID Screen for clinicians (SAS-C).
Please see the main eating disorder page for patient and other resources.
