What Is ARFID? Doctors Explain Why the Eating Disorder’s Rates Are Rising
Avoidant/restrictive food intake disorder, or ARFID, can cause malnutrition and weight loss in children and adults even when body image is not a factor
Stella was eight years old when she stopped eating solid foods. She went from being a “foodie” to strictly consuming liquids, says Briana, Stella’s mother. That diet soon became problematic for Stella, too: later, she removed chunks from her soup and struggled to drink smoothies that contained small seeds. She grew so afraid of swallowing that she’d spit out her saliva. “She said she had a fear of choking,” Briana says. (The last names of Stella and Briana have been withheld for privacy.)In less than a month, Stella became so tired and malnourished that her parents took her to the hospital. Doctors put her on a feeding tube, and they were concerned that the rapid weight loss for her age might cause heart issues. Within 24 hours of being hospitalized, a psychologist diagnosed Stella with avoidant/restrictive food intake disorder, or ARFID, a serious eating disorder that’s become steadily more prevalent globally in recent years. Health care providers and psychologists are now trying to untangle ARFID’s causes, signs and disconcerting rise.Clinicians emphasize that ARFID is much more than a dislike of certain foods. It’s developmentally normal for many kids to go through a picky eating phase between ages two and six. But ARFID presents as a food avoidance so persistent and pervasive that it can cause adults to drop below the minimum health body mass index, or BMI (a hotly debated measurement that links a person’s weight to their height), or to lose so much weight that they experience symptoms of malnutrition, such as vitamin deficiencies, irregular menstrual cycles, low testosterone, hair loss, muscle loss and a constant feeling of being cold. In kids, drastic weight loss from ARFID can cause children to fall off standard U.S. growth charts for healthy development. Developmental issues linked to the loss in weight and calories often spur doctors to recommend supplemental nutritional intake.On supporting science journalismIf you're enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.“We’re not just trying to treat kids who don’t like broccoli. It’s the kid who is malnourished as a result of their food choices,” says James Lock, a psychiatry professor and director of the Child and Adolescent Eating Disorder Program at the Stanford University School of Medicine.An Increasingly Recognized DisorderARFID was formally recognized as a feeding and eating disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. That enabled clinicians to put a name to a condition that had been around but had gone undetected for some time.“Probably there were people who had this syndrome, but they didn’t really talk about it because there’s a stigma around it,” says Jennifer Thomas, co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, who has treated people with ARFID.Wider recognition of the condition is partly driving the recent increase in cases. Real-world data on ARFID cases are lacking, but some studies have reported a global prevalence ranging from 0.35 to 3 percent across all age groups. Certain countries and regions report much higher numbers: a recent study in the Netherlands, for example, found that among 2,862 children aged 10, 6.4 percent had ARFID. The eating disorder clinic that provided specialized care to Stella after she was hospitalized says it treated more than 1,000 people in the U.S. with ARFID in 2024—a 144 percent jump from 2023.“I think that’s one of the things that has made ARFID a challenging eating disorder [to diagnose]—because it is a lot of different things.” —Jessie Menzel, clinical psychologistAnd the National Alliance for Eating Disorders has found that ARFID now accounts for up to 15 percent of all new eating disorder cases. People can experience ARFID at any age, although recently diagnosed cases have mostly been in children and teens. The average age of diagnosis is 11 years old, and 20 to 30 percent of cases are in boys—a higher percentage than other eating disorders, according to the alliance.Signs and SymptomsUnlike other eating disorders such as anorexia nervosa and bulimia, ARFID doesn’t appear to be associated with body image. The problem—and seeming cause—is the food itself and the emotional and physiological response toward it.People with ARFID generally fall into one or several of three categories. According to one study of adults with ARFID, 80 percent of respondents said they were uninterested in eating, 55 percent said they stay away from many foods because of sensory issues, and 31 percent said they avoid food because they are afraid of adverse consequences such as choking or vomiting. About two thirds of the participants were in more than one of these categories.“I think that’s one of the things that has made ARFID a challenging eating disorder [to diagnose]—because it is a lot of different things,” says Jessie Menzel, a clinical psychologist who treats the condition and other eating disorders.There are some common signs that signal ARFID, however. In addition to significant weight loss and signs of malnutrition, ARFID’s physical symptoms include gastrointestinal issues, low body temperature and the growth of a type of soft, fine body hair called lanugo that is typically not present after infancy. Behavioral changes include a lack of appetite, difficulty paying attention, food texture avoidance, extreme selective eating and a fear of vomiting or choking.Although ARFID is classified as an eating disorder, it has a lot of overlap with mental health conditions. A 2022 metastudy found that among people diagnosed with ARFID, up to 72 percent had an anxiety disorder. Studies also suggest the uptick in ARFID cases may be tied to the overall increase in mental health conditions diagnosed in kids. ARFID is particularly pronounced in those who have an anxiety disorder, Thomas says. Her team’s studies have found that about 30 to 40 percent of individuals with ARFID have a co-occurring anxiety disorder in their lifetime. “There are key similarities between ARFID and anxiety disorders,” although they are clinically distinct conditions, Thomas says. “Patients [with ARFID] themselves often describe feeling intense anxiety around food.”Because ARFID and anxiety can be so closely intertwined, it can be difficult to identify one from the other. “Often families will tell us it’s hard to get an [ARFID] diagnosis,” says Doreen Marshall, chief executive officer of the National Eating Disorders Association.ARFID is typically flagged when a child veers from growth curves—charts recommended by the American Academy of Pediatrics to assess a child’s weight and height for their age. “If your lack of interest [in food] has led to your being a couple of standard deviations off your growth curve and you’re not going to hit puberty or grow, that’s a problem,” Lock says.Pinpointing signs of ARFID is trickier when a child has nutritional deficits but is of average or higher body weight. Such discrepancies make it “important that pediatricians listen to parents,” Marshall says. Health care providers should ask parents to describe what they see their child eating or avoiding, she says.ARFID in the BrainScientists don’t fully understand what causes ARFID, although they believe that it’s driven by a combination of genetic, environmental and neurobiological factors. Thomas is currently investigating the latter.In a study published in JAMA Network Open in February, Thomas and her team presented 110 participants with photographs of food, household objects and blurred images and observed their brain activity using functional magnetic resonance imaging (fMRI). The results revealed that the three different ARFID categories correspond to activation of different brain regions. When shown food images, those who fell into the fear-related ARFID category (participants who had a fear of choking, for example) showed hyperactivation of the amygdala, the brain’s fear center. Participants with ARFID who were uninterested in food had lower activation of the hypothalamus, the brain’s appetite-regulation region. People diagnosed with the sensory form of ARFID showed hyperactivation of the brain’s sensory areas, such as the somatosensory cortex or the supplementary motor cortex.“What we found is that there might be different neural circuitry associated with each of the three ARFID presentations,” Thomas says. Results from fMRI have known limitations involving reliability and reproducibility, however. Thomas says that these initial findings need to be replicated to understand if the differences in brain activity are a cause or link to ARFID types; her team is currently collecting data from adults with ARFID for a second study. In a separate 2023 study, her team found that people who lack interest in food experienced a loss of pleasure in a lot of things—a condition known as anhedonia—and that depression partly contributed. “Folks who have that lack-of-interest [version of] ARFID don’t look forward to things in general, not just food,” she says.Understanding the neurological activity involved in ARFID may help clinicians develop more targeted treatments. For now, practitioners rely largely on a treatment known as cognitive-behavioral therapy (CBT), which has shown some success. A 2020 study co-authored by Thomas found that, post-CBT, 70 percent of those treated no longer met the criteria for ARFID. Another study published by Thomas and her colleagues in 2021 in the Journal of Behavioral and Cognitive Therapy found similar results.“With true ARFID, we don’t see a lot of spontaneous remission,” Thomas says. “Recovering from ARFID takes hard work, either at home, making a concerted effort to try new foods, or with a supportive treatment provider.”Most treatments for younger kids rely on parents to manage their child’s eating habits. After a month at the hospital, doctors sent Stella home, and her parents were advised not to cater to Stella’s limited palate. At home, the whole family, including Stella, ate the same meals. When they ate at restaurants, Stella didn’t have to eat a big meal, but she did have to take a few bites of something solid. Within a few months, Stella’s regular eating habits returned, and her ARFID disappeared.Treatments based on controlling eating habits can only go so far, however. They are less effective for people with the types of ARFID that are associated with higher sensitivity to or a lack of interest in food. “I think that’s where it’s so important to understand what’s happening physiologically or neurobiologically,” Menzel says. “That’s going to guide us toward more effective treatments.”If you or someone you know is struggling with an eating disorder, you can contact the National Association of Anorexia Nervosa and Associated Disorders helpline by calling (888) 375-7767. For crisis situations, you can text “NEDA” to 741741 to connect to a trained volunteer at Crisis Text Line.
