“The child does not eat.” “The child only eats breaded meat, white rice and cherry tomatoes.” “The child only eats white or beige things.” These are phrases that can often be heard in pediatric consultations, and that do not always receive the necessary attention. After all, there are many children who eat poorly, or in a capricious way. But a percentage of those minors and adolescents who have a problematic relationship with food could be classified as patients with Arfid, the eating disorder (ED) much less known than anorexia or bulimia, which was classified as such in 2013 and which in recent years has also begun to be diagnosed in adults.
Although there are acronyms in Spanish and Catalan to refer to this diagnosis (Teria, or Avoidance and Restriction of Food Intake Disorder), the name Arfid is generally used, which comes from the same acronym in English. In the Eating Disorders Unit of Sant Joan de Déu, Arfid cases already represent 15% of the total, that is, about 30 cases of the 200 that pass through that center each year. The majority are around ten years old, and after many years of having problems with food.
The percentage of those diagnosed is increasing, not so much because the cases have grown, as happened with anorexia and bulimia after the pandemic – it is estimated that they increased by up to 20% and many cases became worse – but because it is now called Arfid to which it previously received many other names. As Eduardo Serrano, head of the Unit, indicates, “the children were already there, what did not exist was the diagnosis.”
When they arrive there, generally referred from pediatrics or gastroenterology, it is because they are minors who have already suffered a nutritional and growth impact, or it is affecting their social relationships. In some cases, few but increasingly, minors have already had to resort to a gastric tube or button to feed themselves. “They are children,” Serrano clarifies, “who cannot go on an excursion because they would never eat a sandwich, or they cannot go to camps, because they do not contemplate the food outside their home, or they would never go to a restaurant with their families.” .
Within Arfid there are three subtypes of patients, although they sometimes overlap. During the first visits to the ED units, it is common for families to answer the tests and conclude that their children belong to all three at the same time. The first category would be children who lack appetite or who only eat one type of food, to the point that it causes growth retardation or nutritional deficits, but is not related to a feeling of anxiety towards food.
The second profile would have to do with a psychological block and in many cases it occurs in patients with characteristics of autism. They are often bothered by sensory aspects of food, the texture (whether things are crunchy, because they make noise, or too soft) or the color. These are children who, for example, can only eat one food from a certain brand and if it is not available, they reject any other option.
Finally, there is a third group of Arfid patients of the anxious type, who have developed a rejection of food due to a stressful event, gastroenteritis with a lot of vomiting or choking, or suffer from allergies and are afraid even of foods they eat. They are not allergic. In that case, they decide to stop eating or eat much less.
As Dr. Teia Plana, head of the Eating Disorders Unit at Hospital Clínic, clarifies, Arfid is not usually linked to image perception or aesthetic pressure. “These are not patients who stop eating because they will lose weight, they are not worried about gaining weight. If you stop eating orange things, that's not the reason."
Although it is common for families to arrive at ED units thinking that their son or daughter suffers from anorexia because they find chewed but not ingested food hidden around the house. And it is also proven that there are patients who have had Arfid as children who end up developing anorexia or bulimia, or patients with anorexia and bulimia who are retrospectively diagnosed with Arfid.
“The debut in adults is more complicated, it occurs less, the most common thing is that they already had it as children and are diagnosed as adults, as began to happen a few years ago with autism spectrum disorders,” explains Planas. “Maintaining a very selective diet can be the gateway to the most classic EDs. It is not uncommon to see a patient who ate poorly, was very selective as a child and was underweight and as a teenager or adult is treated for anorexia or bulimia.”
As with other new ailments, Arfid has also come across Tik Tok, which is the great modern bazaar of ideas and dissemination. Good, bad and average. Under that label it is easy to find hundreds of videos of people who have received the diagnosis (they or their children) and share with their followers how they are introducing new foods into their diets – one user gets more than 100,000 likes with the videos of “my boyfriend with Arfid trying peas / ranch sauce / fried rice or whatever for the first time” – but some misunderstandings also arise.
Arfid, Plana clarifies, has nothing to do with fad diets that consist of restricting entire food groups. That is, stop eating carbohydrates because you follow a keto diet or stop eating gluten without being celiac. “Just because people are free to self-diagnose intolerances does not make it an eating disorder,” Plana clarifies.
“Diets are now very demedicalized, and people modify their diet according to different parameters. We all have more and less healthy recommendations available to us. What is true is that if you worry a lot about your diet, you are more at risk of developing an eating disorder,” he adds.
The treatment to overcome Arfid is also different. “We work a lot through exposure to food,” explains psychologist Laura Cañas, attached to the ED unit of Sant Joan de Deu and one of the first mental health researchers to publish a paper on this disorder: “When the patient enters the unit, we study its food hierarchy. Those that he eats, those that he doesn't eat but wouldn't mind trying, those that he dislikes... and we began to introduce them, at first individually, and then in a group, with other patients of a similar age. Families are greatly included in this process.”
Although some studies speak of only a 50% success rate of treatments, the criteria for measuring this success are very strict. That is, only those patients who no longer register any Arfid indicators are considered cured. Health workers who are in the day-to-day life of the disease prefer to talk about progressive improvements. “I can tell you that everyone improves,” says Serrano. “There is always some food that comes in and is incorporated normally. If you increase the repertoire by four or five foods, that increases functionality a lot. Now you can go outside, have a sandwich…”
The foods that an Arfid patient does eat are called “safe foods” and these are often ultra-processed with powerful flavors, things like French fries or McDonald's Nuggets. “In fact, home-made fries are often rejected,” Cañas clarifies. With these bases, in the Unit they are trying what is called a chain, going from battered chicken to battered fish for example. Or cook the food to initially give it a more acceptable texture, such as making slices of carrot and grilling them to make them crispy.
At what point can families denormalize the fact that a child eats strangely? When can they think that it may be a pathology? Serrano clarifies that the work does not have to be done so much with the families, who in many cases carry years of worry, as with the health workers themselves. “We professionals are the ones who tend to minimize the symptoms. Of course, because in a pediatric office there are many children who eat poorly. The pediatrician tends to say: 'well, he'll eat', and that will be the case in a large percentage, but not in all. You have to listen to the families. We do a lot of training for pediatricians and family doctors, who are very interested."
