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Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns
Abstract
Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating or feeding disorder characterized by inadequate nutritional or caloric intake leading to weight loss, nutritional deficiency, supplement dependence, and/or significant psychosocial impairment. DSM-5 lists three different eating patterns that can lead to symptoms of ARFID: avoidance of foods due to their sensory properties (e.g., picky eating), poor appetite or limited interest in eating, or fear of negative consequences from eating. Research on the prevalence and psychopathology of ARFID is limited by the lack of validated instruments to measure these eating behaviors. The present study describes the development and validation of the nine-item ARFID screen (NIAS), a brief multidimensional instrument to measure ARFID-associated eating behaviors. Participants were 455 adults recruited on Amazon's Mechanical Turk, 505 adults recruited from a nationally-representative subject pool, and 311 undergraduates participating in research for course credit. Exploratory and confirmatory factor analyses provided evidence for three factors. The NIAS subscales demonstrated high internal consistency, test-retest reliability, invariant item loadings between two samples, and convergent/discriminant validity with other measures of picky eating, appetite, fear of negative consequences, and psychopathology. The scales were also correlated with measures of ARFID-like symptoms (e.g., low BMI, low fruit/vegetable variety and intake, and eating-related psychosocial interference/distress), although the picky eating, appetite, and fear scales had distinct independent relationships with these constructs. The NIAS is a brief, reliable instrument that may be used to further investigate ARFID-related eating behaviors.
... This has in turn led to limited knowledge about its prevalence estimates [11], as well as the optimal approaches to diagnosis and treatment [12]. A recent systematic review [13] that included 30 studies (including 23 from Western countries) showed that prevalence estimates of ARFID in children and adolescents varied widely, ranging from 0.3 to 15.5% in non-clinical samples, [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22].5% in clinical samples from specialised paediatric eating disorders treatment settings, and 32-64% in clinical samples from specialised tertiary care services for feeding problems. It is of note, however, that research on the epidemiology of ARFID in adult populations has been until recently "non-existent or highly inconsistent" [14]. ...
... A recent systematic review [13] that included 30 studies (including 23 from Western countries) showed that prevalence estimates of ARFID in children and adolescents varied widely, ranging from 0.3 to 15.5% in non-clinical samples, [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22].5% in clinical samples from specialised paediatric eating disorders treatment settings, and 32-64% in clinical samples from specialised tertiary care services for feeding problems. It is of note, however, that research on the epidemiology of ARFID in adult populations has been until recently "non-existent or highly inconsistent" [14]. Population-based studies reported prevalence estimates of 0.3-4.8% in general adult populations in Western countries and South-East Asia [15][16][17][18], and of 6.3-11% in clinical adult populations [19,20]. ...
... Throughout the last few years, some research efforts have been directed at designing and validating measurement instruments that capture ARFID behavioural symptoms. A systematic review published in 2020 [12] could identify a total of four measures that showed promising psychometric properties: (1) the Eating Disturbances in Youth Questionnaire (EDY-Q) [21], (2) the Pica, ARFID and Rumination Disorder Interview (PARDI) [22] and a most updated version the PARDI ARFID Questionnaire [PARDI-AR-Q]) [23], (3) the Eating Disorder Examination (ChEDE) [24], and (4) the Nine Item Avoidant/ Restrictive Food Intake Disorder Screen (NIAS) [14]. Among these measures, the NIAS is the briefest selfreport measure that has been exclusively designed and validated to explicitly detect the DSM-5-based presentations of ARFID (i.e., sensory sensitivity, fear of aversive consequences, lack of interest) in a community-based adult population [14]. ...
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, etiology, 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. Good convergent, divergent and concurrent validity was evidenced through adequate patterns of correlations between the NIAS and measures of disordered eating symptoms, psychological distress and well-being. 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.
... Subscales are each scored on a scale from 0 to 15, with higher scores indicating higher levels of each metric (picky eating, lack of interest, and fear). All items may also be summed to calculate a total score, ranging from 0 to 45, with higher scores indicating higher levels of avoidant/restrictive eating broadly (8). Cronbach alphas of the NIAS-PR in the Polish sample were .84, ...
... The three-factor structure of the NIAS-Picky eating, Appetite, and fear-was replicated in the Turkish NIAS-PR. Our findings were consistent with previous studies supporting the three-factor structure and the addition of ARFID subtypes to DSM-5 (1,8,9,20,21). The three NIAS-PR subscales are intercorrelated; however, they represent different constructs. ...
... The three NIAS-PR subscales are intercorrelated; however, they represent different constructs. To better understand the underlying mechanisms that caused avoiding and restricting food intake and to provide more effective therapeutic intervention, it is necessary to reveal these different constructs and presentations of ARFID (8,9). ...
Background and aims: The current study aimed to evaluate the psychometric properties of a Turkish version of The Nine Item Avoidant/Restrictive Food Intake Disorder Screen Parent Report (NIAS-PR), which measures the avoidant/restrictive food intake disorder (ARFID) symptoms by parents. NIAS-PR includes three subscales picky eating, poor appetite/limited interest in eating, and fear of aversive consequences from eating. Also, our secondary aim was to assess the relationship between ARFID-related eating behaviours and emotional-behavioural symptoms of children and parents' psychological status. Methods: The NIAS-PR was translated into Turkish with standard procedures. Two hundred sixty-eight children (133 girls, 49.6%; mean age 8.62, age range from 2 to 18 years) and parents (175 mothers, 65.2%) were included in the study. The factor structure was confirmed using confirmatory factor analysis (CFA). The results were compared to the validated Turkish Children’s Eating Behavior Questionnaire (CEBQ) to determine the convergent validity. Internal consistency (Cronbach alpha coefficient) analysis was used to determine the reliability of the NIAS-PR. Results: The current study provided evidence for the validity of the translated Turkish version of the NIAS-PR in the pediatric population. The three-factor structure of the NIAS—Picky eating, Appetite, and Fear—was replicated in the Turkish NIAS-PR. The NIAS-PR subscales showed the expected patterns of correlations with the CEBQ subscales. The reliability of the Turkish version of NIAS-PR proved to be satisfactory (total Cronbach's alpha=0.90) in the pediatric population (2-18 years). Conclusions: This study demonstrated a good internal consistency of the Turkish version of the NIAS-PR. We confirmed the three-factor structure of the Turkish version of NIAS-PR. NIAS-PR is a brief, reliable instrument for ARFID research in Turkish children and adolescents. The NIAS-PR is developed as a screening questionnaire, so health professionals should use it to investigate ARFID-related eating behaviours further. It is worth mentioning that deepening these eating symptoms with clinical interviews is necessary.
... Yelencich et al. [16] published a study in which they describe another type of eating disorder, the "Avoidant Restrictive Food Intake Disorder (ARFID)", more recently included in the DSM-5 and thus less well known, though diagnostic criteria are well described ( Figure 1). They recruited patients referred to the University of California Los Angeles (UCLA) center for IBD, and, to assess the ARFID risk, an ad hoc questionnaire, the Nine-Item ARFID Screen, was used [17]. The disorder was common in patients with IBD (28 patients out of 161, i.e., 17% of consecutive patients recruited in the referral center), especially in patients with the active disease, who generally avoid one or more food types to relieve Table 3. Similarities and differences between clinical presentation of inflammatory bowel disease (IBD) and ED (adapted from [14]). ...
... The disorder was common in patients with IBD (28 patients out of 161, i.e., 17% of consecutive patients recruited in the referral center), especially in patients with the active disease, who generally avoid one or more food types to relieve Table 3. Similarities and differences between clinical presentation of inflammatory bowel disease (IBD) and ED (adapted from [14]). They recruited patients referred to the University of California Los Angeles (UCLA) center for IBD, and, to assess the ARFID risk, an ad hoc questionnaire, the Nine-Item ARFID Screen, was used [17]. The disorder was common in patients with IBD (28 patients out of 161, i.e., 17% of consecutive patients recruited in the referral center), especially in patients with the active disease, who generally avoid one or more food types to relieve symptoms and to control the disease activity, but it should be noted that patients avoided foods even in the remission phase, because they were afraid of relapsing. ...
... Table 5 reports questionnaires which could be integrated in the dedicated dietitian approach to allow a timely diagnosis in suspect patients. Nine-Item ARFID Screen ARFID (Avoidant Restrictive Food Intake Disorder) Zickgraf et al. [17] ORTO-15 test Orthorexia nervosa Donini et al. [29] Our review has an obvious limitation since it is based on narration and not on a systematic review of the literature; however, we believe it addresses a relevant and somehow neglected topic: the need of increased awareness among gastroenterologists on the prevalence of disordered eating and overt ED in patients with IBD and the need of developing appropriate skills in dealing with them in referral IBD centers. ...
Recent evidence suggests a link between Inflammatory Bowel Disease (IBD) and eating disorders, an emerging complex bidirectional association. Indeed, the overlap of symptoms and signs can lead to delayed diagnosis and misdiagnosis of both conditions, but also the fear of food-induced symptoms, commonly observed in patients with IBD, determines dietary restrictions which in predisposed individuals may induce an overt eating disorder. ARFID (Avoidant Restrictive Food Intake Disorder) and anorexia nervosa are the eating disorders more frequently reported, while disordered eating and orthorexia nervosa are emerging conditions. Disease worsening due to refusal of therapies in patients with anorexia is also a matter of concern and an increased awareness of the possible association of these conditions by gastroenterologists and dietitians is strongly warranted in order for patients to receive the appropriate counseling.
... Previous research has found associations between negative EOE and weight gain, interference with weight loss efforts, binge eating (Ricca et al., 2009), higher waist circumference, body fat, and BMI (Kottinen et al., 2010). Although there has been relatively less focus on EUE as opposed to negative EOE, it has been found to play an important role in eating disorders (ED) and ED symptoms, including restricting symptoms and behaviors in patients with anorexia nervosa (AN) and in the avoidant/restrictive food intake disorder (ARFID) presentation characterized by low appetite and/or limited interest in food (e.g., Reichenberger et al., 2021;Thomas et al., 2018;Zickgraf & Ellis, 2018). Taken together, it can be concluded from the literature that negative EUE has been implicated in restrictive, low-weight EDs, whereas J o u r n a l P r e -p r o o f & Fan, 2020), restrictive eating (Schmidt, Vogel, Hiemisch, Kiess, & Hilbert, 2018), food approach and avoidance tendencies driven by physiological factors (Ellis et al., 2018) as well as emotional factors (Coakley et al., 2022). ...
... Although there has been relatively less focus on EUE as opposed to negative EOE, it has been found to play an important role in eating disorders (ED) and ED symptoms, including restricting symptoms and behaviors in patients with anorexia nervosa (AN) and in the avoidant/restrictive food intake disorder (ARFID) presentation characterized by low appetite and/or limited interest in food (e.g., Reichenberger et al., 2021;Thomas et al., 2018;Zickgraf & Ellis, 2018). Taken together, it can be concluded from the literature that negative EUE has been implicated in restrictive, low-weight EDs, whereas J o u r n a l P r e -p r o o f & Fan, 2020), restrictive eating (Schmidt, Vogel, Hiemisch, Kiess, & Hilbert, 2018), food approach and avoidance tendencies driven by physiological factors (Ellis et al., 2018) as well as emotional factors (Coakley et al., 2022). Additionally, given the fact that variable centered approaches might fail to uncover important trends (e.g., a pattern of emotional eating where individuals exhibit both EOE and EUE; , the present study utilized LCA to study classes of people with emotional eating. ...
... endorsed the second highest level of emotional distress. These findings are in line with the results of, as well as other studies (e.g., Coakley et al. 2022Ellis et al. 2018). We expanded on these previous findings by assessing psychological flexibility -a trait-like factor related to being in contact with the present, being aware and accepting of emotions (pleasant and unpleasant), and engaging in behaviors guided by personal values(Ramaci et al., 2019) --which is believed to protect against emotional dysregulation. ...
Emotional eating (EE) has been consistently associated with obesity, weight gain, and certain eating disorders (EDs). Given the cultural influence on food consumption and eating styles, comparison of EE patterns of individuals in culturally distinct nations (e.g., USA and China) could yield interesting differences in findings. However, given the increasing convergence in eating practices between the above-mentioned nations (e.g., higher reliance on outdoor eating at restaurants among Chinese adolescents), EE patterns might share significant similarities. The present study examined EE patterns of American college students and is a replication of the study done by He, Chen, Wu, Niu, and Fan (2020) on Chinese college students. Responses of 533 participants (60.4% women, 70.1% White, aged 18–52 (mean age = 18.75, SD = 1.35), mean self-reported body mass index = 24.22 kg/m2 and SD = 4.77) on the Adult Eating Behavior Questionnaire (Emotional overeating and emotional undereating subscales) were examined using Latent Class Analysis to identify specific patterns of EE. Participants also completed questionnaire measures of disordered eating and associated psychosocial impairment, depression, stress, and anxiety symptoms, and a measure of psychological flexibility. A solution with four classes emerged, i.e., emotional over- and undereating (18.3%), emotional overeating (18.2%), emotional undereating (27.8%), and non-emotional eating (35.7%). Current findings replicated and extended findings from He, Chen, et al. (2020) in that the emotional over- and undereating class exhibited the highest risks for depression, anxiety, stress, and psychosocial impairment due to disordered eating symptoms as well as lower psychological flexibility. Individuals who have difficulty with awareness and acceptance of their emotions appear to engage in the most problematic form of EE and could benefit from Dialectical behavior therapy and Acceptance and commitment therapy skills training.
... Other definitions of PE include emotional responses having to do with foodsuch as showing no interest in food or meals, or displaying negative emotions before or during eating. These behaviors are better described as emotional undereating, although they are usually associated with PE (Tharner et al. 2014;Zickgraf and Ellis 2018;Zohar et al. 2020;Wolstenholme et al. 2020). In a systematic review of child PE and neophobia, Brown et al. (2016) conclude that the inconsistency of the definition of PE leads to great difficulty in drawing conclusions about prevalence of PE and its relationship to BMI and obesity in children. ...
... The two variables are negatively correlated and are strongly related to maternal reports of PE at earlier developmental stages as well as concurrently. Ellis et al. (2017) developed a 16-item self-report adult picky eating questionnaire (APEQ), with excellent psychometric properties measuring sensitivity to meal presentation, the limitation of food items eaten, lack of appetite or interest in food, and aversion to sour and bitter tastes, which is in wide use in the growing research on adult PE. Zickgraf and Ellis (2018) composed a nine-item avoidant/restrictive screen (NIAS), with three items on PE, three on low appetite (Appetite, A), and three on anxiety pertaining to the gastrointestinal consequences of eating (Fear, F). The items on PE are "I am a picky eater"; "I dislike most of the foods that other people eat"; and "The list of foods that I like and will eat is shorter than the list of foods I won't eat." ...
... The PE score correlates positively with food neophobia and with the food fussiness subscale of the adult eating behavior questionnaire, and negatively with the food enjoyment subscale. It does not correlate with measures of anxiety, depression, and stress (Zickgraf and Ellis 2018). ...
... Available structured clinical interviews that include ARFID criteria either have not been validated for ARFID specifically (e.g., Eating Disorder Assessment for DSM-5 [6]; Structured Clinical Interview for DSM-5 [7]) or are lengthy and may not be practical for routine use in clinical settings (e.g., Pica, ARFID, and Rumination Disorder Interview [8]; Eating Disorder Examination ARFID module [9]). Available self-report measures of ARFID symptoms include the Nine-Item ARFID Screen (NIAS) [10], which provides data on the three ARFID phenotypes that may motivate food avoidance and restriction in ARFID (including subscales labeled "picky eating, " "fear, " and "low appetite"). However, screening positive or negative for ARIFD on the NIAS has not been validated against diagnosis via clinical interview, and cut-points for a possible ARFID diagnosis have only recently been proposed [11]. ...
... Healthy controls from the neurobiology study did not meet criteria for any current psychiatric disorder on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) [17]. Adults and children from MTurk and Rally were classified as HC through a self-report battery; they had to score below clinical cut points including < 2.3 on the Eating Disorder Examination-Questionnaire [2], < 44 on the State-Trait Anxiety Inventory trait scale [18], < 16 on the Center for Epidemiological Studies Depression Scale [19], and < 10, 9, and 10, respectively, on the Picky Eating, Appetite, and Fear subscales of the Nine-Item ARFID Scale [10,11]. To ensure data quality for individuals recruited through MTurk, we set our survey such that individuals could not participate twice. ...
... PARDI-AR-Q subscale scores correlated highly with one another, but still loaded onto distinct factors. This was also true of NIAS subscale scores in the current study, as well as in prior studies [10]. Taken together, these findings are consistent with existing reports of overlap among ARFID phenotypes [28] and lend support to a three-dimensional model of ARFID in which there are three distinct phenotypes and individuals may present with one, two, or all three [29]. ...
Background
The Pica, ARFID, and Rumination Disorder Interview (PARDI) is a structured interview that can be used to determine diagnosis, presenting characteristics, and severity across three disorders, including avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate the psychometric properties of a questionnaire focused specifically on ARFID (PARDI-AR-Q), which has the potential to provide related information with less participant burden.
Methods
Adolescents and adults ( n = 71, ages 14–40 years) with ARFID ( n = 42) and healthy control participants (HC, n = 29) completed the PARDI-AR-Q and other measures. A subset of the ARFID group ( n = 27) also completed the PARDI interview.
Results
An exploratory factor analysis of proposed subscale items identified three factors corresponding to the ARFID phenotypes of avoidance based on the sensory characteristics of food, lack of interest in eating or food, and concern about aversive consequences of eating. Further analyses supported the internal consistency and convergent validity of the PARDI-AR-Q subscales, and subscale ratings on the questionnaire showed large and significant correlations (all p -values < 0.001; r ’s ranging from 0.48 to 0.77) with the corresponding subscales on the interview. The ARFID group scored significantly higher than HC on all subscales. Furthermore, 90% of the ARFID group scored positive on the PARDI-AR-Q diagnostic algorithm while 93% of the HC scored negative.
Conclusions
Though replication in larger and more diverse samples is needed, findings provide early support for the validity of the PARDI-AR-Q as a self-report measure for possible ARFID in clinical or research settings.
... Other definitions of PE include emotional responses having to do with foodsuch as showing no interest in food or meals, or displaying negative emotions before or during eating. These behaviors are better described as emotional undereating, although they are usually associated with PE (Tharner et al. 2014;Zickgraf and Ellis 2018;Zohar et al. 2020;Wolstenholme et al. 2020). In a systematic review of child PE and neophobia, Brown et al. (2016) conclude that the inconsistency of the definition of PE leads to great difficulty in drawing conclusions about prevalence of PE and its relationship to BMI and obesity in children. ...
... The two variables are negatively correlated and are strongly related to maternal reports of PE at earlier developmental stages as well as concurrently. Ellis et al. (2017) developed a 16-item self-report adult picky eating questionnaire (APEQ), with excellent psychometric properties measuring sensitivity to meal presentation, the limitation of food items eaten, lack of appetite or interest in food, and aversion to sour and bitter tastes, which is in wide use in the growing research on adult PE. Zickgraf and Ellis (2018) composed a nine-item avoidant/restrictive screen (NIAS), with three items on PE, three on low appetite (Appetite, A), and three on anxiety pertaining to the gastrointestinal consequences of eating (Fear, F). The items on PE are "I am a picky eater"; "I dislike most of the foods that other people eat"; and "The list of foods that I like and will eat is shorter than the list of foods I won't eat." ...
... The PE score correlates positively with food neophobia and with the food fussiness subscale of the adult eating behavior questionnaire, and negatively with the food enjoyment subscale. It does not correlate with measures of anxiety, depression, and stress (Zickgraf and Ellis 2018). ...
... Qualtrics Panel Studies are frequently utilized for participant recruitment in behavioral and social sciences research (Cogan et al., 2020;Gillig et al., 2018;Zickgraf & Ellis, 2018). By using marketing research panels with respondents who have previously agreed to participate on a panel, Qualtrics Panel Studies quickly recruits participants with specified characteristics. ...
... Qualtrics Panel Studies have frequently been used with difficult-to-reach populations, including transgender individuals (Cogan et al., 2020), people with disordered eating behaviors (Zickgraf & Ellis, 2018), and attitudinal research towards minoritized populations (Gillig et al., 2018). ...
Adverse Childhood Experiences and Intimate Partner Violence in Gender Minority Populations - Claire Mason McCown, M.P.S.
Childhood adversity has been linked to numerous health and mental health concerns in adulthood (Felitti et al., 1998). Among the many outcomes associated with adverse childhood experiences (ACEs), victimization and perpetration of intimate partner violence (IPV) remains a public health crisis. Research has found that those identifying as gender minority individuals are disproportionately impacted by IPV (Messinger, 2017; Peitzmeier et al., 2020). Further, gender minority individuals experience equivalent, if not higher, rates of ACEs when compared to their cisgender counterparts (Baams, 2018; Juárez-Chávez et al., 2018; Schnarrs et al., 2019; Tobin & Delaney, 2019). While many factors contribute to the pathway from ACEs to IPV, the role of internalized transphobia (IT) in this relation is poorly understood. However, previous research has underscored the role of internalized shame in relation to both ACEs and IPV (Rood et al., 2017; Thaggard & Montayre, 2019; Thomson & Jaque, 2018b). Internalized transphobia may therefore serve as a mediator in the relationship between adverse childhood experiences and intimate partner violence. Using a cross-sectional quantitative single administration survey design, this research aimed to better understand the relation between ACEs, IT, and IPV in adults identifying as gender minorities. This study used a mediated regression model to discern if internalized transphobia mediated the relationship between childhood adversity and intimate partner violence. Findings from this research indicated that while internalized transphobia did not mediate the relationship between ACEs and IPV, IT was still predictive of IPV. Endorsement of ACEs also predicted endorsement of IPV.
Keywords: Gender Minority, Adverse Childhood Experiences, Intimate Partner Violence
... Specific recommendations regarding diet composition and macronutrient breakdown for patients with NAFLD could not be inferred from existing IF studies, given that IF protocols typically included ad libitum intake during the feeding period, and diet composition and nutrient intake during this feeding period were often not assessed. However, practical, general recommendations for IF implementation for both clinicians and patients are included in Table 2 [28,29]. ...
... • Excessive weight loss (greater than 1 kg per week) • Micronutrient deficiencies (iron, folate, vitamin B12) a Abridged patient-generated subjective global assessment [28]. b Nine item avoidant/restrictive food intake disorder screen [29]. Abbreviations: ADF, alternate-day fasting; BMI, body mass index; IF, intermittent fasting; NAFLD, nonalcoholic fatty liver disease; NIAS, nine item avoidant/restrictive food intake disorder screen; PG-SGA, patient-generated subjective global assessment; TRF, time-restricted feeding. ...
Intermittent fasting is a non-pharmacological dietary approach to management of obesity and metabolic syndrome, involving periodic intervals of complete or near-complete abstinence from food and energy-containing fluids. This dietary strategy has recently gained significant popularity in mainstream culture and has been shown to induce weight loss in humans, reduce gut and systemic inflammation, and improve gut microbial diversity and dysbiosis (largely in animal models). It has been hypothesized that intermittent fasting could be beneficial in the management of nonalcoholic fatty liver disease, given the condition’s association with obesity. This review summarizes protocols, potential mechanisms of action, and evidence for intermittent fasting in nonalcoholic fatty liver disease. It also highlights practical considerations for implementing intermittent fasting in clinical practice. A search of the literature for English-language articles related to intermittent fasting or time-restricted feeding and liver disease was completed in PubMed and Google Scholar. Potential mechanisms of action for effects of intermittent fasting included modulation of circadian rhythm, adipose tissue and adipokines, gut microbiome, and autophagy. Preclinical, epidemiological, and clinical trial data suggested clinical benefits of intermittent fasting on metabolic and inflammatory markers in humans. However, there was a paucity of evidence of its effects in patients with nonalcoholic fatty liver disease. More clinical studies are needed to determine mechanisms of action and to evaluate safety and efficacy of intermittent fasting in this population.
... Addressing these limitations, we conducted a prospective study evaluating the preliminary effectiveness of a cognitive-behavioral, family-centered PHP for children and adolescents with ARFID by systematically measuring outcomes at admission, discharge, and six-and twelve-month follow-up. We used measures that assess ARFID-specific symptomatology, including the Nine-Item ARFID Screen (NIAS) (Zickgraf & Ellis, 2018) and the Food Fussiness and Satiety Responsiveness subscales of the Children's Eating Behavior Questionnaire (CEBQ) (Wardle et al., 2011). We hypothesized that children and adolescents with ARFID would experience significant improvements in ARFID symptomatology and body weight throughout treatment in the PHP. ...
... gov/growthcharts). (Zickgraf & Ellis, 2018). ARFID symptoms were assessed with the parentreport version of the NIAS. ...
Objective:
This study explored the preliminary effectiveness of a partial hospitalization program (PHP) for children/adolescents with avoidant/restrictive food intake disorder (ARFID). We evaluated how ARFID symptoms changed from admission to discharge, and collected follow-up data on symptoms and outpatient care following PHP discharge.
Method:
Twenty-two children/adolescents with ARFID (77.3% White, 63.6% female) completed measures assessing ARFID symptomatology at admission and discharge from a PHP for eating disorders. Six months and twelve months following their discharge, participants were contacted to complete study measures again and take part in an interview assessing follow-up care.
Results:
Paired samples t tests indicated that participants demonstrated increases in weight and decreases in ARFID symptomatology from admission to discharge with medium to large effects. All participants reported receiving some form of outpatient treatment following discharge, with the type of outpatient services varying across participants. Data from the 86% of participants who completed the six-month follow-up and 50% who completed the twelve-month follow-up suggest that participants generally maintained treatment gains following PHP discharge.
Discussion:
Participants experienced symptom improvements from admission to discharge and appeared to maintain these gains after discharge. These results provide preliminary evidence that PHPs are an effective treatment option for children and adolescents with ARFID.
Public significance statement:
This study provides preliminary evidence that intensive, evidence-based PHPs are effective in treating ARFID. Our findings suggest that children and adolescents with ARFID who receive flexible, cognitive-behavioral, family-centered treatment in a PHP for EDs experience improvements in weight and ARFID symptomatology from admission to discharge. Despite receiving variable and nonstandardized outpatient treatment, individuals with ARFID appear to maintain treatment gains 6 and 12 months after discharge in a PHP.
... As in other feeding disorders, the EDY-Q or K-SADS can be used to evaluate eating disorder symptoms. Self-report questionnaire measures such as the Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013), Nine-Item ARFID Screen (NIAS; Zickgraf & Ellis, 2018), and PARDI self-report can and should be employed to differentiate symptoms of ARFID and anorexia/bulimia in older youth and adults. This step is essential, as physical and health consequences of both ARFID and anorexia nervosa symptomatology can be similar. ...
Developmental disorders are diverse, common, and impairing; still, many clinicians lack comprehensive training in their assessment. This review presents thorough guidelines for the evaluation and diagnosis of common communication, sleeping, feeding, and elimination disorders that often onset in the early developmental period and that are commonly encountered in clinical practice. Thorough guidance on the evidence-based assessment of developmental disorders is critical, as they are prevalent, impairing, and commonly comorbid with other psychiatric disorders of childhood. This review is the first of its kind—providing critically needed, step-by-step guidance on the existing evidence-based methodologies and assessment tools available for diagnosis. This review also makes clear the dire need for further development and validation of relevant screening and diagnostic measure and calls for specific attention to the development of specific screening and diagnostic assessment measures for feeding disorders and elimination disorders in particular. Clinicians and researchers alike may find this article useful in guiding diagnostic, treatment, and research procedures.
... The NIAS is a nine-item measure used to screen for avoidant/restrictive intake disorder (ARFID) among adolescents and adults, including transgender populations. Scores of 0-45 are used to characterize three restrictive eating patterns, including picky eating, poor appetite or limited interest in eating, and fear of eating consequences [14,15]. ...
Background
Transgender youth and young adults are at increased risk for eating disorders, including binge eating disorder, yet few measures have been validated for screening purposes with the transgender population.
Methods
The purpose of this study was to provide initial evidence for the internal consistency and convergent validity of the Adolescent Binge Eating Disorder questionnaire (ADO-BED) in a sample of transgender youth and young adults. 208 participants completed the ADO-BED as part of a routine nutrition screening protocol at a gender center. Exploratory factor analysis and confirmatory factor analysis was used to establish the factor structure of the ADO-BED. Relationships between the ADO-BED, Sick, Control, One Stone, Fat, Food (SCOFF), Nine Item Avoidant/restrictive Intake Disorder (NIAS), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and demographic characteristics were explored.
Results
Analyses revealed a one-factor structure of the ADO-BED with good fit to the data in the present sample. The ADO-BED was shown to be significantly related to all convergent validity variables, except the NIAS.
Conclusions
The ADO-BED is a valid measure to screen for BED among transgender youth and young adults. Healthcare professionals can screen all transgender patients for BED, regardless of body size, in order to effectively identify and manage binge eating concerns.
... Given these measurement challenges, it is critical for future research to develop and validate brief screening measures for ARFID. Recent research has shown preliminary support for the nine-item ARFID screen (NIAS) (33), which measures restrictive eating associated with appetite, fear, and picky eating, and recent recommendations have suggested using the NIAS in combination with another screening tool (34). However, to date, no brief screening tool for ARFID has been validated. ...
Background
Avoidant/restrictive food intake disorder (ARFID) is a serious, albeit under-researched, feeding or eating disorder. This exploratory study utilized data from adult respondents to the National Eating Disorders Association (NEDA) online eating disorder screen to validate items assessing the presence of ARFID and examine the prevalence, clinical characteristics, and correlates of a positive ARFID screen compared to other probable eating disorder/risk categories.
Methods
Among 47,705 adult screen respondents between January 2022 and January 2023, the prevalence of a positive ARFID screen was calculated. Chi-square tests and t-tests compared demographics, eating disorder attitudes and behaviors, suicidal ideation, current eating disorder treatment status, and eating disorder treatment-seeking intentions between respondents with possible ARFID and other eating disorder diagnostic and risk categories. Clinical characteristics of respondents with possible ARFID were also examined.
Results
2,378 (5.0%) adult respondents screened positive for ARFID. Respondents with possible ARFID tended to be younger, male, and have lower household income, and were less likely to be White and more likely to be Hispanic/Latino than most other diagnostic/risk groups. They had lower weight/shape concerns and eating disorder behaviors than all other diagnoses but higher BMI than those with AN. 35% reported suicidal ideation, 47% reported intentions to seek treatment for an eating disorder, and 2% reported currently being in treatment. The most common clinical feature of ARFID was lack of interest in eating (80%), followed by food sensory avoidance (55%) and avoidance of food due to fear of aversive consequences (31%).
Conclusions
Findings from this study indicated that ARFID was prevalent among adult screen respondents and more common among individuals who were younger, male, non-White, Hispanic, and lower income relative to those with other eating disorders or at risk for an eating disorder. Individuals with possible ARFID frequently reported suicidal ideation and were rarely in treatment for an eating disorder. Further research is urgently needed to improve advances in the assessment and treatment of ARFID and improve access to care in order to prevent prolonged illness duration.
... Currently available screening measures for ARFID tap different aspects of presentations, with limited validation data yet available (Dinkler & Bryant-Waugh, 2021). Some, such as the Nine-Item ARFID screen (NAIS; Zickgraf & Ellis, 2018), focus on the core drivers of restricted eating behaviour (i.e., concern about aversive consequences, sensory based avoidance, low interest in food). Others, such as the ARFID-Brief Screener (ARFID-BS) (Dinkler et al., 2022) Furthermore, there has been some confusion among clinicians whether experiencing psychosocial impairment alone is enough to diagnose ARFID, or whether individuals must also experience one of the other criteria more closely associated with unmet energy or nutritional needs Coelho et al., 2021;Eddy et al., 2019). ...
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.
... 21,40-42 Contrastingly, patients who lack interest in eating and food may present with chronic low appetite and early satiety resulting in lower BMIs. 8,43 This was supported by our findings. ...
Importance
Avoidant restrictive food intake disorder (ARFID) is a newly recognised eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and in the International Classification of Diseases, Eleventh Revision which shows great heterogeneity in its clinical presentation.
Objectives
Here, we examined the clinical characteristics of ARFID and explored the associations between ARFID symptoms and traits of anxiety. We also investigated whether individuals with ARFID show a different clinical presentation based on their biological sex or comorbid autism spectrum disorder (ASD) diagnosis.
Design, Setting, and Participants
We recruited 261 consecutive patients from the specialised ARFID outpatient service at the Maudsley Centre for Child and Adolescent Eating Disorders, Michael Rutter Centre, Maudsley Hospital, London, United Kingdom.
Main Outcomes and Measures
The parents of the patients completed the Pica, ARFID, Rumination Disorder - ARFID - Questionnaire (PARDI-AR-Q), the Revised Children's Anxiety and Depression Scale (RCADS) and reported biological sex of their offspring. Age, height, and weight were obtained from medical records. Clinicians reported on comorbid ASD diagnosis and anxiety traits using the Current View Tool.
Results
This cross-sectional study included 261 child and adolescent ARFID patients (133 [51%] female) with a median age of 12.7 years (IQR=9.2 to 15.8). Patients' BMI-for-age z-scores ranged from -6.75 to 4.07 (median = -1.07, IQR = -2.25 to -0.01).
Patients' comorbid traits of anxiety had the highest correlations with symptoms on the concern about aversive consequences driver of ARFID: panic disorder correlated with physical feelings of panic and anxiety when eating (r=0.53, p=7.74 x 10-31) and being afraid to eat (r=0.42, p=5.13 x 10-21); generalised anxiety correlated with physical feelings of panic and anxiety when eating (r=0.44, p=7.72 x 10-23); and separation anxiety correlated with avoiding eating situations (r=0.36, p=2.01 x 10-15). Sensory sensitivity to the appearance of food positively correlated with separation anxiety (r=0.40, p=1.52 x 10-16) and generalised anxiety (r=0.36, p=7.16 x 10-18).
The sensory sensitivities (RR = 0.96; 95% CI, 0.85 to 1.09; P = .53), lack of interest (RR = 1.14; 95% CI, 1.03 to 1.28; P = .02) and concern about aversive consequences (RR = 1.27; 95% CI, 1.03 to 1.56; P = .03) drivers were independent of patient sex. Comorbid ASD was reported in 74 (28%) ARFID patients. Their parents reported higher rates of food-related sensory sensitivities (RR = 1.26; 95% CI, 1.09 to 1.45; P=0.002) and lack of interest (RR = 1.19; 95% CI, 1.05 to 1.34; P=0.006) driving their child's avoidant and restrictive eating than parents of ARFID patients without ASD (127 [49%]).
Conclusions and Relevance
Our study highlights that ARFID patients present with varying combinations and severity of food-related sensory sensitivities, lack of interest and concern about aversive consequences which drive their avoidant and restrictive eating. ARFID does not discriminate between male and female children and adolescents or those with or without ASD. Anxiety and ASD can co-occur with ARFID, and ASD may accentuate food-related sensory sensitivities and lack of interest. Healthcare professionals should be aware of the multi-faceted and heterogenous nature of ARFID; it is important that comprehensive multidisciplinary assessments are administered to sufficiently understand the drivers of the eating behaviour and associated physical health, nutritional, and psycho-social risk and impact.
... Bu nedenle, yetişkinlerde seçici yeme için değerlendirmeler geliştirmek gereklidir (16). Seçici yemeyi ölçmeyi hedefleyen ölçekler çoğunlukla gıda neofobisi ve sınırlı besin çeşitliliğine odaklanırken; seçici yemenin önemli tutum ve davranışlarını içermemektedir (15,17,18). Bu nedenle, Ellis ve ark. ...
Amaç: Bu çalışmada The Adult Picky Eating Questionnaire’ın Türkçe uyarlaması olan Yetişkin Seçici Yeme Ölçeği’nin geçerlilik ve güvenilirliğini ortaya koymak amaçlanmıştır. Yöntem: Metodolojik araştırma tasarımı kullanılan çalışma, 2021-2022 akademik yılında XXX Üniversitesi’nde 222 katılımcıyla yürütülmüştür. Google Formlar’da yapılandırılmış bir anket aracılığıyla Bilgi Formu, Yetişkin Seçici Yeme Ölçeği ve Yeme Tutum Testi uygulanmıştır. İstatistiksel değerlendirmede iç tutarlılık katsayısı, faktör analizleri ve korelasyonları IBM SPSS26® yazılımı ile yapılmıştır. Bulgular: Yetişkin Seçici Yeme Ölçeği’nin 114 kişi ile yürütülen pilot çalışmasında, Cronbach’s Alpha değeri 0.795 bulunarak, ölçeğin oldukça güvenilir olduğu olduğu ve ölçekten madde çıkartılmadan, geçerlilik analizine uygun olduğu belirlenmiştir. Çalışmanın 222 örneklemli Açımlayıcı Faktör Analizi’nde, Kaiser-Mayer-Olkin değeri 0.788 ile örneklem hacminin iyi düzeyde yeterli olduğu ve Bartlett Küresellik testi ile χ2=722.637 ve p=0.000 düzeyinde istatistiki açıdan anlamlılık olduğu bulunmuştur. Faktör yükleri >0.20 ve öz değerleri >1 olan ve toplam varyansın %56.768’ini açıklayan dört faktörlü bir yapı saptanmıştır. Çalışmanın Doğrulayıcı Faktör Analizi’nde 16 maddelik versiyonun uyum iyiliği indeksleri RMSEA=0.010; CFI=0.998; GFI=0.975; NFI=0.933; SRMR=0.059; AGFI=0.966; χ2/df=0.906 olarak yeterli uyum gösterdiği saptanmıştır. İç tutarlılık analizinde Cronbach’s Alpha katsayısı 0.829 olarak bulunmuştur. Sonuç: Yetişkinlerde seçici yemeyi ölçmeye yarayan Yetişkin Seçiçi Yeme Ölçeği’nin Türkçe Formu’nun geçerli ve güvenilir olduğu gösterilmiştir.
... 32 The Nine Item ARFID Screen (NIAS) has nine items assessing ARFID symptoms on a from 0 (strongly disagree) to 5 (strongly agree) summed into three subscales (fear of adverse consequences, sensory sensitivity, and lack of interest/appetite; 0-15) and a total score (0-45), with higher scores indicating greater symptom severity. 33 The Fear of Food Questionnaire (FFQ) has 18 items assessing food related fears on a scale from 0 (not at all) to 5 (absolutely) averaged into five subscales (GI Fears, Food Fears, Food Avoidance, Social Impairment, and Distress/Loss of Pleasure) and a Total Score, with higher scores indicating greater fear around eating. 34 We also reported clinician-rated Clinical Global Impression-Improvement scores and patient-rated Subject Clinical Global Impression-Improvement 35 at Session 5. ...
Background:
Exposure-based cognitive-behavioral therapy (exposure-CBT) is efficacious for irritable bowel syndrome (IBS). However, few patients receive exposure-CBT due to a lack of behavioral health providers trained in brain-gut behavior therapies. Nurse practitioners (NPs) could fill a critical need for scalable delivery methods. In a pragmatic investigation of a 5-session NP-delivered exposure-CBT for adults with Rome IV-defined IBS, we evaluated treatment feasibility and acceptability and explored changes clinical outcomes.
Methods:
Exposure-CBT was delivered as part of routine care involving four sessions every other week and a 2-month booster session. Patients could electively participate in an observational study including pre-, mid-, and post-treatment surveys and a post-treatment qualitative interview. Independently coded ratings of NP treatment protocol adherence and competence ratings were completed from audio recordings, rated on a 1 (not at all) to 5 (completely) scale.
Results:
Twenty-five patients consented (ages 22-67 years; 76% female; 48% IBS-diarrhea predominant). There was high feasibility-adherence average = 4.1, NP competence average = 4.8, 72% treatment completion, 93% satisfaction scores ≥3. Treatment satisfaction was high (rated as 4/4 "very satisfied" by n = 9 and as 3/4 "mostly satisfied" by n = 5). There were improvements in clinical outcomes across treatment with large effects for IBS-symptom severity (-53%; Hedge's g = 1.0; 95% confidence interval [CI] = 0.5, 1.5) and IBS quality of life (+31%; Hedge's g = 0.8; 95% CI = 0.4, 1.2).
Conclusions:
NP-delivered exposure-CBT for IBS was initially feasible and acceptable with promising clinical improvements. Findings will inform a future NIH Stage 1B/ORBIT Phase IIB pilot randomized control trial.
... Consider the four items in the SSP Taste/Smell Sensitivity subscale, "avoids certain taste or food smells that are typically part of children's diets", "will only eat certain tastes", "limits self to particular food textures/temperatures", "picky eater, especially regarding food textures". These items are similar to several items included in common measures of feeding problems, for example "my child dislikes certain foods and won't eat them" from the Brief Autism Mealtime Behavior Inventory (Lukens & Linscheid, 2008), "will only eat select types of foods" and "only eats certain textures" from the Screening Tool for Feeding Problems, child revision (Seiverling et al., 2011), or "my child is a picky eater" and "my child dislikes most of the foods that other kids his/her age eat" from the nine-item ARFID screen (Zickgraf & Ellis, 2018). Several items on the SSP are similar to items on measures of feeding problems so it was possible these overlapping items influenced the outcomes of some studies involving relations between sensory sensitivity and feeding problems. ...
Past research suggests that children, particularly those with autism spectrum disorder, with general behavioral inflexibility to objects, persons, and environments may be at risk for feeding problems. However, questions remain about whether feeding problems are better predicted by behavioral inflexibility or sensory sensitivity, and whether general or food-specific measures are stronger predictors. The present study compared two types of behavioral inflexibility (general, food-specific) and two types of sensory sensitivity (food touch, temperature) for their association with children’s feeding problems. Participants were 372 children and their parents who completed surveys on their children’s demographics, as well as measures of behavioral inflexibility, sensory sensitivity, and feeding problems. The children, all referred to a feeding clinic were 71.8% male and had a mean age of 71.53 months. For this sample, 33. 7% had autism spectrum disorder (ASD), 28.7% had special needs other than ASD, and 37.5% had no special needs. ANCOVAs examined child demographics (age, weight status, medical problems, gender, special needs status) for their associations with each measure of inflexibility and sensitivity, finding that ASD was associated with more general and food-specific inflexibility, and younger age was associated with more food touch sensitivity. Hierarchical multiple regressions, which controlled for demographics, including ASD diagnosis, compared the four measures of inflexibility and sensitivity as predictors for each feeding problem. These analyses found food-specific behavioral inflexibility was the only significant predictor of all three feeding problems. Results suggest reducing the severity of children’s feeding problems, clinicians focus on increasing behavioral flexibility as it relates to food.
... People living in larger bodies may experience ARFID and should be assessed and managed in the same way as for people not living in a larger body. The nine-item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) is an assessment instrument which have been developed for adults [165]. The Child Food Neophobia Scale (CFNS) is a good psychometric measure of food avoidance in children [166]. ...
Introduction:
The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.
Aim:
The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.
Methods:
The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.
Recommendations:
Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.
Conclusions:
This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.
... Further, the two instruments are designed to measure overlapping but different constructs. The NIAS was developed as a screening instrument that can identify the primary presentation(s) of restrictive eating causing ARFID symptoms [36,37]. The Polish tool assesses ARFID eating restrictions and the secondary somatic effects that may result from a poor diet. ...
The aim of the present study was to develop and validate the Avoidant/Restrictive Food Intake Disorder Questionnaire—Parents Report (ARFID-Q-PR), a new tool to diagnose ARFID, based on a report submitted by Polish mothers of children aged 2 to 10 years. In total, 167 mothers of boys and girls aged 2 to 10 participated in the study. We used the ARFID-Q-PR and the Nine Items Avoidant/Restrictive Food Intake Disorder Screen—Parents Report (NIAS-PR). In addition, all mothers were asked to provide information on age, sex, height and weight, chronic somatic diseases, neurodevelopmental and mental disorders as well as intellectual disability of their children. Results of the reliability analysis demonstrated that the ARFID-Q-PR had adequate internal consistency (Cronbach’s alpha of 0.84). The stability of the ARFID-Q-PR factorial structure was confirmed. It is composed of three subscales: (1) attitudes to food; (2) justification for restrictions; (3) somatic symptoms. Our findings demonstrated that the ARFID-Q-PR total score was positively associated with the NIAS-PR total score. In addition, children with developmental and mental disorders substantially demonstrated more ARFID symptoms than did the children in the general population. The Polish version ARFID-Q-PR can be used to recognize the ARFID symptoms in young children by the main feeder in the family—mother or father.
... The Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS; Zickgraf & Ellis, 2018), which assesses reasons individuals restrict or avoid their food, was used to measure symptoms of avoidant restrictive food intake disorder (ARFID). The NIAS has three-subscales, which correspond to the three presentations of ARFID described in the DSM-5 (i.e., selective/picky eating, poor appetite/limited interest in eating, and fear of negative consequences of eating). ...
Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 · 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 · 3 [9 · 86, 12 · 8] pounds and the average change in EDE-QS score was -6 · 31 [-8 · 67, -4 · 10] points. Similar reductions were seen for depression (-2 · 62 [-4 · 24, -1 · 04]), anxiety (-1 · 44 [-1 · 12, 0 · 78]), and caregiver burden (-4 · 41 [2 · 45, 6 · 31]). Caregiver self-efficacy increased by 4 · 56 [3 · 53, 5 · 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.
... Both showed good psychometric properties, though were validated in small sample sizes [86]. Three articles presented empirical data on screening instruments designed to identify ARFID: the Eating Disturbances in Youth Questionnaire (EDY-Q; Hilbert and van Dyck, 2016) and the Nine Item ARFID Screen (NIAS) (Zickgraf and Ellis 2018) [87][88][89]. Both showed promising results with further study warranted, noting that the literature regarding ARFID screening, particularly in adults, is scant [86]. ...
Background
Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.
Methods
This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.
Results
Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.
Conclusions
A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many.
Plain English Summary
Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia’s National Eating Disorders Research and Translation Strategy 2021–2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.
Transgender youth experience elevated rates of eating disorders, yet few screening measures have been validated with transgender patients. The purpose of this study was to provide initial evidence for the internal consistency and convergent validity of the Sick, Control, One Stone, Fat, Food (SCOFF) in a sample of transgender youth. Two hundred eight participants completed the SCOFF as part of a routine screening protocol. Exploratory factor analysis and confirmatory factor analysis were used to establish the factor structure of the SCOFF in this sample. Relationships between the SCOFF, Adolescent Binge Eating Disorder (ADO-BED), Nine-Item Avoidant/Restrictive Intake Disorder (NIAS), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and demographic characteristics were explored. The SCOFF was significantly related to all convergent validity variables, with moderate correlations with other eating disorder scales (ADO-BED and NIAS). The SCOFF is a valid measure to screen for eating disorders among transgender youth and young adults.
Avoidant/restrictive food intake disorder (ARFID) is an uncommon but complex eating disorder characterized by extreme picky eating without poor body image or fear of weight gain. Intake is limited by volume or variety of food, driven by fear of adverse consequences associated with ingestion, sensory sensitivities to food properties, or a lack of interest in eating. Avoidance or restriction of food intake can lead to low body weight or failure to thrive, nutritional deficiencies, reliance on enteral feeding, and psychosocial impairment. The presentation of ARFID varies depending on severity, variety, and volume of diet; therefore, medical evaluation should be comprehensive, should be tailored to patient needs, and should include screening for commonly co-occurring psychiatric conditions. Cognitive behavioral therapy and/or family-based therapy, in conjunction with pharmacotherapy and/or hospital refeeding, have demonstrated therapeutic benefit. Available literature is sparse and largely limited to children and adolescents. Additional studies are needed to evaluate therapeutic interventions, medical follow-up, and prognosis.
Background:
Avoidant restrictive food intake disorder (ARFID) is a new eating disorder with a heterogeneous clinical presentation. It is unclear which patient characteristics contribute to its heterogeneity.
Methods:
To identify these patient characteristics, we performed symptom-level correlation and driver-level regression analyses in our cross-sectional study in up to 261 ARFID patients (51% female; median age = 12.7 years) who were assessed at the Maudsley Centre for Child and Adolescent Eating Disorders, London between November 2019 and July 2022.
Findings:
Symptoms across the three drivers 1) avoidance based on sensory characteristics of food; 2) apparent lack of interest in eating; and 3) concern about aversive consequences positively correlated with each other. Patients' anxiety traits showed the greatest positive correlations with symptoms of concern about aversive consequences of eating. Patient sex was not significantly associated with any of the three ARFID drivers. Patients with comorbid autism spectrum disorder (ASD; 28%) showed more food-related sensory sensitivities (RR = 1.26) and greater lack of interest in eating (RR = 1.18) than those of patients without ASD (49%).
Interpretation:
In our clinical sample, the ARFID drivers occurred together and did not show clinically meaningful differences between the sexes. ASD may accentuate food-related sensory sensitivities and lack of interest, but may not drive a completely different symptom presentation. ARFID is multi-faceted and heterogenous, requiring a comprehensive multidisciplinary assessment to sufficiently understand the drivers of the restrictive eating behaviour. Results need replication in larger samples with more statistical power.
Funding:
None.
Objective:
The United Kingdom Eating Disorders Genetics Initiative (EDGI UK), part of the National Institute for Health and Care Research (NIHR) Mental Health BioResource, aims to deepen our understanding of the environmental and genetic etiology of eating disorders. EDGI UK launched in February 2020 and is partnered with the UK eating disorders charity, Beat. Multiple EDGI branches exist worldwide. This article serves the dual function of providing an in-depth description of our study protocol and of describing our initial sample including demographics, diagnoses, and physical and psychiatric comorbidities.
Method:
EDGI UK recruits via media and clinical services. Anyone living in England, at least 16 years old, with a lifetime probable or clinical eating disorder is eligible to sign up online: edgiuk.org. Participants complete online questionnaires, donate a saliva sample for genetic analysis, and consent to medical record linkage and recontact for future studies.
Results:
As of September 2022, EDGI UK recruited 7435 survey participants: 98% female, 93.1% white, 97.8% cisgender, 65.9% heterosexual, and 52.1% have a university degree. Over half (57.8%) of these participants have returned their saliva DNA kit. The most common diagnoses are anorexia nervosa (48.3%), purging disorder (37.8%), bulimia nervosa (37.5%), binge-eating disorder (15.8%), and atypical anorexia nervosa (7.8%).
Conclusion:
EDGI UK is the largest UK eating disorders study and efforts to increase its diversity are underway. It offers a unique opportunity to accelerate eating disorder research. Researchers and participants with lived experience can collaborate on projects with unparalleled sample size.
Public significance statement:
Eating disorders are debilitating and costly for society but are under-researched due to underfunding. EDGI UK is one of the largest eating disorder studies worldwide with ongoing recruitment. The collected data constitute a resource for secondary analysis. We will combine data from all international EDGI branches and the NIHR BioResource to facilitate research that improves our understanding of eating disorders and their comorbidities.
Objective:
This study assessed the factorial, divergent, and criterion-related validity of the Youth-Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (Y-NIAS) in a paediatric clinical sample at initial evaluation for an eating disorder (ED).
Method:
Participants included 310 patients (82.9% female, 77.4% White, Age M = 14.65) from a tertiary ED clinic. Confirmatory factor analysis (CFA) evaluated the three-factor of the Y-NIAS. One-way analysis of variance compared Y-NIAS scores across diagnoses. A receiver operating curve analysis assessed the ability of each subscale to identify ARFID presentations from the full sample. Two logistic regressions assessed the criterion-related validity of the obtained Y-NIAS cut-scores.
Results:
CFA supported the original three-factor structure of the Y-NIAS. Clinically-elevated scores were observed in all diagnostic groups except for binge-eating disorder. Subscales were unable to discriminate ARFID cases from other ED diagnoses. Cut scores were identified for picky eating subscale (10) and Fear subscale (9), but not for Appetite subscale. In combination with the ED Examination Questionnaire (EDE-Q), classification accuracy was moderate for ARFID (62.7%) and other EDs (89.4%).
Discussion:
The Y-NIAS demonstrated excellent factorial validity and internal consistency. Findings were mixed regarding the utility of the Y-NIAS for identifying clinically-significant ARFID presentations from other ED diagnoses.
Avoidant/restrictive food intake disorder (ARFID) was introduced as a new feeding and eating disorder diagnosis in DSM-5. ARFID is characterized by avoidant/restrictive eating resulting in a host of medical and psychological sequelae. Cognitive-behavioral therapy for ARFID (CBT-AR) aims to reduce nutritional compromise and increase opportunities for exposure to novel foods, resulting in amelioration of negative feelings and predictions about the consequences of eating. In this chapter, we describe CBT-AR and illustrate its application using a case example.KeywordsCognitive-behavioral therapyExposureAvoidant/restrictive food intake disorderARFIDFeeding and eating disordersSensory sensitivityFear of aversive consequencesLack of interest in eating or food
Introduction:
Mental health disorders are common in inflammatory bowel disease (IBD) and affect patients' quality of life, impacting on disease outcomes and health care-related costs.
Areas covered:
Even if psychological issues in IBD patients are highly burdened in terms of quality of life, psychiatric comorbidities still receive less attention into routine care than the physical symptoms of the disease. The present review provides an overview of recent literature, focusing on the association between perceived stress and IBD outcomes. For this purpose, the epidemiology of more common psychological comorbidities in IBD and their potential effect on the onset and disease course have been examined. Moreover, therapeutic interventions in the management of these patients have also been evaluated.
Expert opinion:
Screening of patients at high risk of psychological issues is currently an unmet, clinical need in the management of IBD. Under-diagnosed and under-treated mental health disorders in IBD patients may impact outcomes, leading to increased disability and health-care utilization and associated costs. A patient-tailored, integrated model of care in the management of IBD is required to optimize disease outcomes and improve patients' quality of life.
Fear approach is a theorized mechanism of exposure treatment for anxiety-based disorders. However, there are no empirically established self-report instruments measuring the tendency to approach feared stimuli. Because clinical fears are heterogeneous, it is important to create a measure that is adaptable to person- or disorder-specific fears. The current study (N = 455) tests the development, factor structure, and psychometric properties of a self-report instrument of fear approach broadly and the adaptability of this measure to specific eating disorder fears (i.e., food, weight gain). Factor analyses identified a unidimensional, nine-item factor structure as the best fitting model. This measure had good convergent, divergent, and incremental validity and good internal consistency. The eating disorder adaptations retained good fit and strong psychometric properties. These results suggest that this measure is a valid, reliable, and adaptable measure of fear approach, which can be used in research and exposure therapy treatment for anxiety-based disorders.
Background:
Patients with 'underlying' autism spectrum disorder (ASD) constitute a significant minority in adult out-patient psychiatry. Diagnoses of previously unrecognised ASD are increasing in adults. Characteristics of patients with autism within adult out-patient psychiatry have not been sufficiently explored, and there have not been any systematic comparisons of characteristics between patients with and those without autism within adult out-patient psychiatric populations.
Aims:
To examine psychiatrically relevant characteristics in autistic adult psychiatric out-patients, and to compare the characteristics with non-autistic adult psychiatric out-patients.
Method:
We assessed 90 patients who were referred to a Swedish psychiatric out-patient clinic and screened for ASD during 2019-2020. Sixty-three patients met the DSM-5 criteria for ASD or 'subthreshold' ASD. The 27 who did not meet the criteria for ASD were used as a comparison group. Assessments were made with structured and well-validated instruments, including parent ratings of developmental history.
Results:
No differences were found between the groups regarding self-reported sociodemographic variables. The ASD group showed a higher number of co-occurring psychiatric disorders than the non-ASD group (t(88) = 5.17, 95% CI 1.29-2.91, d = 1.19). Functional level was lower in the ASD group (t(88) = -2.66, 95% CI -9.46 to -1.27, d = -0.73), and was predicted by the number of co-occurring psychiatric disorders.
Conclusions:
The results underscore the need for thorough assessment of psychiatric disorders in autistic patients in adult psychiatric services. ASD should be considered as a possible 'underlying' condition in adult psychiatry, and there is no easy way of ruling out ASD in this population.
Objective:
Cognitive behavioral therapy for Avoidant Restrictive Food Intake Disorder (ARFID; CBT-AR) is an emerging treatment for ARFID. However, this treatment modality has yet to be examined among older adults (e.g., older than 50 years) or with adults presenting with feeding tubes. To inform future versions of CBT-AR, we present the results of a singular case study (G) of an older male with the sensory sensitivity phenotype of ARFID who presented for treatment with a gastrostomy tube.
Methods:
G was a 71-year-old male who completed eight sessions of CBT-AR in a doctoral training clinic. ARFID symptom severity and comorbid eating pathology changes were examined pre- and post-treatment.
Results:
Posttreatment, G reported significant decreases in ARFID symptom severity and no longer met diagnostic criteria for ARFID. Furthermore, throughout treatment, G reported significant increases in his oral food consumption (vs. calories being pushed through the feeding tube), solid food consumption, and the feeding tube was ultimately removed.
Discussion:
This study provides proof of concept that CBT-AR is potentially effective for older adults and/or those presenting for treatment with feeding tubes. Validation of patient efforts and severity of ARFID symptoms emerged as core to treatment success and should be emphasized when training clinicians in CBT-AR.
Public significance:
Cognitive behavior therapy for ARFID (CBT-AR) is the leading treatment for this disorder; however, it has yet to be tested among older adults or those with feeding tubes. This single-patient case study demonstrates that CBT-AR may be efficacious in reducing ARFID symptom severity among older adults with a feeding tube.
High rates of overlap exist between disorders of gut-brain interaction (DGBI) and eating disorders, for which common interventions conceptually conflict. There is particularly increasing recognition of eating disorders not centered on shape/weight concerns, specifically avoidant/restrictive food intake disorder (ARFID) in gastroenterology treatment settings. The significant comorbidity between DGBI and ARFID highlights its importance, with 13% to 40% of DGBI patients meeting full criteria for or having clinically significant symptoms of ARFID. Notably, exclusion diets may put some patients at risk for developing ARFID and continued food avoidance may perpetuate preexisting ARFID symptoms. In this review, we introduce the provider and researcher to ARFID and describe the possible risk and maintenance pathways between ARFID and DGBI. As DGBI treatment recommendations may put some patients at risk for developing ARFID, we offer recommendations for practical treatment management including evidence-based diet treatments, treatment risk counseling, and routine diet monitoring. When implemented thoughtfully, DGBI and ARFID treatments can be complementary rather than conflicting.
There are no standard assessment approaches for Avoidant Restrictive Food Intake Disorder (ARFID). We describe our approach to multi-disciplinary assessment after assessing more than 550 patients with ARFID. We collected online survey (ARFID-specific instruments, measures of anxiety, depression) measures. Electronic medical record (EMR) data (mental health and gastrointestinal (GI) diagnoses, micronutrient and bone density assessments, and growth parameters) were extracted for the 239 patients with ARFID seen between 2018 and 2021 with both parent and patient responses to online surveys. We identified 5 subtypes/combinations of subtypes: low appetite; sensory sensitivity; fear + sensory sensitivity; fear + low appetite; fear + sensory sensitivity + low appetite. Those with appetite-only subtype had higher mean age (14.0 years, p<0.01) and the lowest average BMI z-score (-1.74, p<0.01) compared to other subtypes. Our experience adds to understanding of clinical presentations in patients with ARFID and may aid in assessment formulation.
Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.
Background:
Gastrointestinal (GI)-specific anxiety has been identified as a treatment target in irritable bowel syndrome. However, GI-specific anxiety has been understudied in other GI functional/motility disorders. Among adults with gastroparesis, we aimed to: (1) initially validate a measure of GI-specific anxiety, the Visceral Sensitivity Index (VSI); and (2) evaluate the relationship between GI-specific anxiety and gastroparesis symptom severity and quality of life, compared to measures of anxiety, depression, and somatization.
Methods:
Consecutive adult patients (N = 100) with gastroparesis presenting for initial consultation completed a series of self-report measures including the VSI. We conducted a confirmatory factor analysis of the VSI one-factor structure and tested internal consistency and convergent validity. We then performed hierarchical linear regression analyses to explore associations between VSI and gastroparesis symptom severity and overall quality of life.
Key results:
Confirmatory factor analysis revealed that the original VSI one-factor structure overall fit well [χ2 (90) = 220.1, p < 0.0001; SRMR = 0.08; RMSEA = 0.12; CFI = 0.96]. The VSI also had excellent internal consistency (α = 0.99) and convergent validity (r = 0.29-0.56; all p < 0.01). Higher GI-specific anxiety was significantly associated with greater gastroparesis symptom severity, including nausea/vomiting, fullness/satiety, and upper abdominal pain scores beyond depression, anxiety, or somatization (all p = <0.01-0.01). Additionally, higher GI-specific anxiety was significantly associated with lower mental health-related quality of life, beyond gastroparesis symptom severity, depression, anxiety, or somatization (p = 0.01).
Conclusions & inferences:
The VSI is an adequate measure of GI-specific anxiety in patients with gastroparesis. Higher GI-specific anxiety was associated with increased patient-reported gastroparesis symptom severity and decreased quality of life, beyond depression/anxiety.
Background:
Though a growing body of research suggests that greater positive psychological well-being in irritable bowel syndrome (IBS) may be protective, existing brain-gut behavior therapies primarily target negative psychological factors. Little is known about how positive psychological factors in IBS relate to IBS symptoms, health-related quality of life (HRQoL), or adherence to key health behaviors, such as physical activity and diet modification. Accordingly, per the ORBIT model of behavioral treatment development for chronic diseases, we explored potential connections between psychological constructs and IBS symptoms, health behavior engagement (physical activity and dietary modification), and HRQoL in a qualitative study to inform the development of a novel brain-gut behavior therapy.
Methods:
Participants with IBS completed self-report assessments and semi-structured phone interviews about relationships between positive and negative psychological constructs, IBS symptoms, health behavior engagement, and HRQoL.
Key results:
Participants (n = 23; 57% female) ranged in age from 25 to 79 (mean age = 54). IBS subtypes were similarly represented (IBS-diarrhea [n = 8], IBS-constipation [n = 7], and IBS-mixed [n = 8]). Participants described opposing relationships between positive and negative psychological constructs, IBS symptoms, health behavior engagement, and HRQoL, respectively, such that experiencing positive constructs largely mitigated IBS symptoms, boosted health behavior participation, and improved HRQoL, and negative constructs exacerbated symptoms, reduced health behavior participation, and worsened HRQoL.
Conclusions and inferences:
Participants with IBS linked greater positive psychological well-being to moderated IBS symptoms and better HRQoL and health behavior participation. An intervention to cultivate greater well-being may be a novel way to mitigate IBS symptoms, boost health behavior participation, and improve HRQoL in IBS.
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.
Summary
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.
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.
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.
Introduction:
There is evidence for increased risk of eating disorders in individuals with diet-treated chronic illnesses, however, data in patients with Cystic Fibrosis (CF) is less clear. No studies have evaluated avoidant/restrictive food intake disorder (ARFID) in the CF population. We investigated the prevalence of eating disorders, including ARFID, in adolescents and young adults with CF.
Methods:
Patients with CF aged 14-35 years were recruited to complete three validated surveys: (1)Eating Disorder Examination Questionnaire (EDE-Q), (2)Nine-Item Avoidant/Restrictive Food Intake Disorder Scale (NIAS), and (3)Cystic Fibrosis Questionnaire-Revised (CFQ-R). Univariate linear regression analysis identified baseline risk factors associated with these survey scores. Variables with univariate p<0.20 were considered for inclusion in a multivariable linear regression model. Backwards stepwise linear regression was used to identify the final model.
Results:
A total of 52 patients enrolled. The prevalence of a positive screen on the EDE-Q was 9.6%, and on the NIAS was 13.5%. The CFQ-R eating and weight subscales were associated with scores on the EDE-Q, and CFQ-R eating subscale and being dF508 homozygous were correlated with the NIAS total score.
Discussion:
A clinically significant number of participants screened positive for eating disorders on the EDE-Q and NIAS. Scores on the eating and weight scales of the CFQ-R were associated with the scores on these surveys. Further work is needed to better understand the optimal way to use such tools to screen and treat for eating disorders in individuals with CF. This article is protected by copyright. All rights reserved.
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.
Background
Orthorexia nervosa (ON) involves obsessive thoughts about healthy eating and distress related to this obsession. There is still dispute over whether ON should be considered on the obsessive-compulsive spectrum, the eating disorder (ED) spectrum, or as its own disorder. Based on current research, orthorexic behaviors seem to be closely related to eating disorder behaviors. However, given the range of instruments used to measure ED and ON, and the lack of consistency in the specific ED domains explored, a review of the current literature is warranted.
Objective
The objective of this study was to review the literature relating ON and ED symptoms in an effort to understand the nature of their relationship, and to identify ED symptom domains most closely related to ON.
Methods
A search was conducted on PubMed, Science Direct, and Web of Science using the term “orthorexia” and at least one of the following: “anorexia nervosa,” “bulimia nervosa,” “eating disorder,” “arfid,” “restrictive,” “body image,” “weight concern,” “shape concern.” After exclusion criteria were applied, 42 articles were included in the review.
Results
The results indicated that ON is consistently related to both trait and disordered restrictive eating symptoms of anorexia nervosa, and weight control motivations for food choice. However, ON was less consistently related to binge-spectrum eating disorder symptoms, emotional eating, uncontrolled eating, or body dissatisfaction/shape and weight concerns.
Conclusion
The finding that ON symptoms are related to restraint and weight loss efforts, but not to body dissatisfaction or dysregulated eating suggests that ON may represent a distinct ED.
Background
The aims of this study were to evaluate the factor structure of the newly developed Adult Eating Behaviour Questionnaire (AEBQ) (Hunot et al., Appetite 105:356-63, 2016) in an Australian sample, and examine associations between the four food approach and four food avoidance appetitive traits with body mass index (BMI).
Methods
Participants (N = 998) recruited between May and October 2016 via a university research participation scheme and online social network sites completed an online version of the AEBQ and self-reported demographic and anthropometric data. Of the sample, 84.8% were females, 29.6% had completed a university degree and the overall mean age was 24.32 years (SD = 8.32). Confirmatory factor analysis (CFA) was used to test three alternative factor structures (derived from issues raised in the original development study): the original 8 factor model, a 7 factor model with Food Responsiveness and Hunger scales combined, and a 7 factor model with the Hunger scale removed.
Results
The CFA revealed that the original 8 factor model was a better fit to the data than the 7 factor model in which Food Responsiveness and Hunger scales were combined. However, while reliability estimates for 7 of the 8 scales were good (Cronbach’s α between 0.70-0.86), the reliability of the Hunger scale was modest (0.67) and dropping this factor resulted in a good fitting model. All food avoidance scales (except Food Fussiness) were negatively associated with body mass index (BMI) whereas Emotional Overeating was the only food approach scale positively associated with BMI.
Conclusions
The study supports the use of the AEBQ as a reliable and valid measure of food approach and avoidance appetitive traits in adults. Longitudinal studies that examine continuity and stability of appetitive traits across the lifespan will be facilitated by the addition of this measurement tool to the literature.
We present a case of an eight-year-old boy with a specific phobia of vomiting who developed subsequent food restriction and weight loss. Our case report includes a review of treatment modalities for specific phobias including cognitive behavioural and exposure therapy in young children and the importance of parental involvement in the treatment process. After an initial assessment and diagnosis of this boy with emetophobia, treatment took place over ten subsequent visits, one hour each in duration. His treatment included a cognitive approach utilizing exposure therapy to re-introduce foods to his diet, working through a fear hierarchy, addressing cognitive distortions/misconceptions and psychoeducational supports. Intermittent reinforcement was applied to help extinguish what we believe was an associatively learned fear of vomiting. Outcomes of the treatment were measured by changes in behaviour and overall increase in food intake reported by the patient's parents. On completion of treatment, the family was no longer concerned with the amount and variety of food he was eating, the patient reported less nausea, and he was more likely to eat in public. A post-treatment three-week telephone follow-up showed continued gains. Congruent with reported literature
,
this case confirms and highlights the efficacy of exposure therapy and age-appropriate cognitive treatment adaptations in treatment of emetophobia. In addition, parental education and participation is recommended in treatment of child cases.
Aim:
The aim of this study was to investigate symptoms of swallowing difficulty in Panic Disorder (PD) patients and the factors associated with these symptoms.
Methods:
In the pre-phase of the study, 22 PD patients who were treated in psychiatry outpatient clinics and who were found to have swallowing difficulty were evaluated. PD patients were asked to write about their thoughts, feelings and behaviors associated with swallowing difficulty. Later, these texts were examined and 41 expressions were identified in which patients described their swallowing difficulty. These expressions were evaluated by mental health workers in the field and twelve different swallowing difficulty items were defined. In the main phase of the study, 119 PD outpatients were evaluated using twelve different swallowing difficulty items and psychometric tests [Panic and Agoraphobia Scale (PAS), Separation Anxiety Symptom Inventory (SASI), Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI-1/STAI-2)].
Results:
As a result of the validity and reliability analysis, a valid one-factor instrument with ten items was obtained. Cronbach's alpha value for this measurement tool was 0.89 and it was termed the "Swallowing Anxiety Scale (SAS)". It was found that SAS items "always" accompany PD patients at rates of 5-20.2%. According to hierarchical regression analysis, 35% of SAS scores were explained by PAS, SASI, STAI-2 and BDI scores.
Conclusion:
Swallowing difficulty items in PD patients involved anxious, phobic and somatic symptoms associated with swallowing. In addition, swallowing difficulty symptoms in PD patients can be confounded with eating disorder symptoms.
Background
One presentation of Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by picky eating, i.e., selective eating based on the sensory properties of food. The present study has two aims. The first is to describe distress and impairment in individuals with ARFID secondary to picky eating. The second is to determine whether eating behaviors hypothesized to be specific to picky eating can differentiate picky eaters with and without ARFID from typical eaters (e.g., individuals not reporting picky or disordered eating) and individuals who strongly endorse attitudes associated with anorexia and bulimia (eating disordered attitudes).
Methods
Participants were recruited from Amazon’s Mechanical Turk (N = 325) and an online support group for adult picky eaters (N = 81). Participants were grouped based on endorsement of picky eating, ARFID symptoms, and elevated eating disordered attitudes on the Eating Attitudes Test (EAT-26). The resulting four eating behavior groups were compared on measures of distress and impairment (e.g., anxiety/depression and, obsessive compulsive disorder symptoms, eating-related quality of life) and on measures of eating behaviors associated with picky eating (e.g., food neophobia, inflexibility about preparation and presentation of preferred foods, sensitivity to sensory stimuli, and eating from a very narrow range of foods). The groups were compared using one way ANOVA with post-hoc Tamhane’s T2 tests.
Results
On measures of distress and impairment, participants with ARFID reported higher scores than both typical eaters and picky eaters without ARFID, and comparable scores to those with disordered eating attitudes. Three of four measures of picky eating behavior, eating inflexibility, food neophobia, and eating from a range of 20 or fewer foods, distinguished picky eaters with and without ARFID form typical eaters and those with disordered eating attitudes. Picky eaters with ARFID reported greater food neophobia and eating inflexibility, and were more likely to eat from a narrow range of foods, compared to picky eaters without ARFID.
Conclusions
Adult picky eaters can be differentiated from those with symptoms of anorexia and bulimia by their stronger endorsement of food neophobia and inflexible eating behaviors, and by eating from a very narrow range of foods. Picky eaters with ARFID symptoms can be differentiated from picky eaters without these symptoms on the basis of these three eating behaviors, and by their higher endorsement of internalizing distress, OCD symptoms, and eating-related quality of life impairment. This study provides evidence that ARFID symptoms exist independently of symptoms of other eating disorders and are characterized by several distinct eating behaviors. In a clinical analogue sample of disordered eaters, ARFID symptoms were associated with distress and impairment at levels comparable to symptoms of anorexia and bulimia.
The Child Eating Behaviour Questionnaire (CEBQ) is a validated parent-report measure of appetitive traits associated with weight in childhood. There is currently no matched measure for use in adults. The aim of this study was to adapt the CEBQ into a self-report Adult Eating Behaviour Questionnaire (AEBQ) to explore whether the associations between appetitive traits and BMI observed in children are present in adults. Two adult samples were recruited one year apart from an online survey panel in 2013 (n = 708) and 2014 (n = 954). Both samples completed the AEBQ and self-reported their weight and height. Principal component analysis (PCA) was used to derive 35 items for the AEBQ in Sample1 and confirmatory factor analysis (CFA) was used to replicate the factor structure in Sample 2. Reliability of the AEBQ was assessed using Cronbach's α and a two week test-retest in a sub-sample of 93 participants. Correlations between appetitive traits measured by the AEBQ and BMI were calculated. PCA and CFA results showed the AEBQ to be a reliable questionnaire (Cronbach's α > 0.70) measuring 8 appetitive traits similar to the CEBQ [Hunger (H), Food Responsiveness (FR), Emotional Over-Eating (EOE), Enjoyment of Food (EF), Satiety Responsiveness (SR), Emotional Under-eating (EUE), Food Fussiness (FF) and Slowness in Eating (SE)]. Associations with BMI showed FR, EF (p < 0.05) and EOE (p < 0.01) were positively associated and SR, EUE and SE (p < 0.01) were negatively associated. Overall, the AEBQ appears to be a reliable measure of appetitive traits in adults which translates well from the validated child measure. Adults with a higher BMI had higher scores for ‘food approach’ traits (FR, EOE and EF) and lower scores for ‘food avoidance’ traits (SR, EUE and SE).
Picky eating (also known as fussy, faddy or choosy eating) is usually classified as part of a spectrum of feeding difficulties. It is characterised by an unwillingness to eat familiar foods or to try new foods, as well as strong food preferences. The consequences may include poor dietary variety during early childhood. This, in turn, can lead to concern about the nutrient composition of the diet and thus possible adverse health-related outcomes. There is no single widely accepted definition of picky eating, and therefore there is little consensus on an appropriate assessment measure and a wide range of estimates of prevalence. In this review we first examine common definitions of picky eating used in research studies, and identify the methods that have been used to assess picky eating. These methods include the use of subscales in validated questionnaires, such as the Child Eating Behaviour Questionnaire and the Child Feeding Questionnaire as well as study-specific question(s). Second, we review data on the prevalence of picky eating in published studies. For comparison we present prevalence data from the UK Avon Longitudinal Study of Parents and Children (ALSPAC) in children at four time points (24, 38, 54 and 65 months of age) using a study-specific question. Finally, published data on the effects of picky eating on dietary intakes (both variety and nutrient composition) are reviewed, and the need for more health-related data and longitudinal data is discussed.
Copyright © 2015. Published by Elsevier Ltd.
This study sought to determine the distribution of early-onset restrictive eating disturbances characteristic of the new DSM-5 diagnosis, avoidant/restrictive food intake disorder (ARFID) in middle childhood, as well as to evaluate the screening instrument, Eating Disturbances in Youth-Questionnaire (EDY-Q). A total of 1,444 8- to 13-year-old children were screened in regular schools (3rd to 6th grade) in Switzerland using the self-report measure EDY-Q, consisting of 12 items based on the DSM-5 criteria for ARFID. 46 children (3.2 %) reported features of ARFID in the self-rating. Group differences were found for body mass index, with underweight children reporting features of ARFID more often than normal and overweight children. The EDY-Q revealed good psychometric properties, including adequate discriminant and convergent validity. Early-onset restrictive eating disturbances are commonly reported in middle childhood. Because of possible negative short- and long-term impact, early detection is essential. Further studies with structured interviews and parent reports are needed to confirm this study's findings.
Structural equation modeling (SEM) is a vast field and widely used by many applied researchers in the social and behavioral sciences. Over the years, many software pack-ages for structural equation modeling have been developed, both free and commercial. However, perhaps the best state-of-the-art software packages in this field are still closed-source and/or commercial. The R package lavaan has been developed to provide applied researchers, teachers, and statisticians, a free, fully open-source, but commercial-quality package for latent variable modeling. This paper explains the aims behind the develop-ment of the package, gives an overview of its most important features, and provides some examples to illustrate how lavaan works in practice.
Purpose
To evaluate the DSM-5 diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) in children and adolescents with poor eating not associated with body image concerns.
Methods
A retrospective case-control study of 8–18-year-olds, using a diagnostic algorithm, compared all cases with ARFID presenting to seven adolescent-medicine eating disorder programs in 2010 to a randomly selected sample with anorexia nervosa (AN) and bulimia nervosa (BN). Demographic and clinical information were recorded.
Results
Of 712 individuals studied, 98 (13.8%) met ARFID criteria. Patients with ARFID were younger than those with AN (n = 98) or BN (n = 66), (12.9 vs. 15.6 vs. 16.5 years), had longer durations of illness (33.3 vs. 14.5 vs. 23.5 months), were more likely to be male (29% vs. 15% vs. 6%), and had a percent median body weight intermediate between those with AN or BN (86.5 vs. 81.0 and 107.5). Patients with ARFID included those with selective (picky) eating since early childhood (28.7%); generalized anxiety (21.4%); gastrointestinal symptoms (19.4%); a history of vomiting/choking (13.2%); and food allergies (4.1%). Patients with ARFID were more likely to have a comorbid medical condition (55% vs. 10% vs. 11%) or anxiety disorder (58% vs. 35% vs. 33%) and were less likely to have a mood disorder (19% vs. 31% vs. 58%).
Conclusions
Patients with ARFID were demographically and clinically distinct from those with AN or BN. They were significantly underweight with a longer duration of illness and had a greater likelihood of comorbid medical and/or psychiatric symptoms.
Specific phobia of vomiting (SPOV) is a clinical condition with early onset, chronic course and substantial psychosocial impairment due to a rigorous avoidance behavior. A primary symptom which drives patients to consult a medical practitioner is nausea. In this study our aim was to further analyze this symptom of SPOV and examined its role in the development and manifestation of the phobia. We conducted an internet survey in the german SPOV-internet-forum. We calculated a nausea score and grouped participants in a high-and low-nausea group to examine the relationship between nausea and characteristics of the fear of vomiting. In this sample (N = 131), nausea was fairly common in most participants with fear of vomiting. Participants in the high-nausea group had significantly higher ratings of subjective fear and significantly longer duration of fear of vomiting. Additionally, the high-nausea group contained more participants with a body mass index below 19 than the low-nausea group. The present findings suggest that nausea is a core symptom in SPOV which is closely related to intensity of the fear, duration of the fear, and body weight. Future research should investigate if nausea-specific design of treatment could improve therapy outcome.
Given the limited number of reported cases in literature, it might be concluded that it is rare to develop a choking phobia in childhood. However, it appears as though confusion in terminology and the time lapse between the onset of the disorder and treatment often results in the diagnosis being missed. In this article, we discuss a review of the clinical symptoms, differential diagnosis, comorbidity, etiology, and treatment options for choking phobia. We present a case series, describing the successful EMDR treatment of choking phobia for 4 children and adolescents, with positive outcomes achieved in 1 or 2 sessions. In addition, a detailed transcript is presented of a 15-year-old girl with a choking phobia related to an incident that occurred 5 years previously. The rapid elimination of symptoms in all 4 cases indicates that EMDR can be an effective treatment for choking phobias resulting from previous disturbing events. Randomized research on this promising intervention is strongly suggested.
There are three fundamental problems in Sijtsma (Psychometrika, 2008): (1) contrary to the name, the glb is not the greatest lower bound of reliability but rather is systematically less than
ω
t
(McDonald, Test theory: A unified treatment, Erlbaum, Hillsdale, 1999), (2) we agree with Sijtsma that when considering how well a test measures one concept, α is not appropriate, but recommend ω
t
rather than the glb, and (3) the end user needs procedures that are readily available in open source software.
Keywordsreliability-internal consistency-homogeneity-test theory-coefficient alpha-coefficient omega-coefficient beta
An organism's survival depends crucially on its ability to detect and acquire nutriment. Attention circuits interact with cognitive and motivational systems to facilitate detection of salient sensory events in the environment. Here we show that the human attentional system is tuned to detect food targets among nonfood items. In two visual search experiments participants searched for discrepant food targets embedded in an array of nonfood distracters or vice versa. Detection times were faster when targets were food rather than nonfood items, and the detection advantage for food items showed a significant negative correlation with Body Mass Index (BMI). Also, eye tracking during searching within arrays of visually homogenous food and nonfood targets demonstrated that the BMI-contingent attentional bias was due to rapid capturing of the eyes by food items in individuals with low BMI. However, BMI was not associated with decision times after the discrepant food item was fixated. The results suggest that visual attention is biased towards foods, and that individual differences in energy consumption--as indexed by BMI--are associated with differential attentional effects related to foods. We speculate that such differences may constitute an important risk factor for gaining weight.
Food neophobia has been studied extensively in children, but its causal origins and relationship to eating behavior in adults are not well understood. We studied genetic and environmental effects on variation in food neophobia, measured using the Food Neophobia Scale, and explored associations between food neophobia and personality, pleasantness and use frequency of food groups, and body mass index in young adult twins (N = 1175, aged 20–25 years, 54.7% women). In women, additive genetic effects (heritability) accounted for 61% of variation in food neophobia, whereas in men, shared environmental effects explained 45% of the variation. Food neophobia negatively correlated with the personality trait Openness, corrected for the structural overlap (r = −0.23), and in women, these two traits had a genetic correlation (r
g = −0.39). In addition, food neophobia negatively correlated with pleasantness and use frequency of fruits and vegetables and of fish and with mean pleasantness of foods. Once evolutionarily important, food neophobia should at present be considered in nutrition counseling as a possible barrier to a balanced diet.
To test the hypothesis that quantitative variation in eating behaviour traits shows a graded association with weight in children.
Cross-sectional design in a community setting.
Data were from 406 families participating in the Physical Exercise and Appetite in CHildren Study (PEACHES) or the Twins Early Development Study (TEDS). Children were aged 7-9 years (PEACHES) and 9-12 years (TEDS).
Weights and heights were measured by researchers. Body mass index (BMI) s.d. scores were used to categorize participants into underweight, healthy weight, overweight and obese groups, with an additional division of the healthy weight group into higher and lower healthy weight at the 50th centile. Eating behaviour traits were assessed with the Child Eating Behaviour Questionnaire (CEBQ), completed by the parents on behalf of their child. Linear trend analyses compared CEBQ subscale scores across the five weight groups.
Satiety Responsiveness/Slowness in Eating and Food Fussiness showed a graded negative association with weight, whereas Food Responsiveness, Enjoyment of Food, Emotional Overeating and Desire to Drink were positively associated. All effects were maintained after controlling for age, sex, ethnicity, parental education and sample. There was no systematic association with weight for Emotional Undereating.
These results support the idea that approach-related and avoidance-related appetitive traits are systematically (and oppositely) related to adiposity, and not exclusively associated with obesity. Early assessment of these traits could be used as indicators of susceptibility to weight gain.
The Children's Eating Behaviour Questionnaire (CEBQ) is a parent-report measure designed to assess variation in eating style among children. In the present study we translated the CEBQ and examined its factor structure in a sample of parents of 6- and 7-year-old children in the Netherlands. Additionally, associations between the mean scale scores of the instrument and children's body mass index (BMI) were assessed.
In total, 135 parents of primary school children aged 6 and 7 completed the questionnaire (response rate 41.9%). Children's BMI was converted into standardised z-scores, adjusted for child gender and age to examine the association between mean scale scores and child weight status.
Results generally confirmed the theoretical factor structure, with acceptable internal reliability and between-subscale correlations. Linear regression analyses revealed that BMI z-scores were positively associated with the 'food approach' subscales of the CEBQ (food responsiveness, enjoyment of food, emotional overeating) (beta's 0.15 to 0.22) and negatively with 'food avoidant' subscales (satiety responsiveness, slowness in eating, emotional undereating, and food fussiness) (beta's -0.09 to -0.25). Significant relations with child BMI z-scores were found for food responsiveness (p = 0.02), enjoyment of food (p = 0.03), satiety responsiveness (p = 0.01) and slowness in eating (p = 0.01).
The results support the use of the CEBQ as a psychometrically sound tool for assessing children's eating behaviours in Dutch children and the study demonstrates its applicability in overweight-related studies.
Eating disorders have a profound and highly specific impact on psychosocial functioning. The aim of this research was to develop a measure of such secondary impairment. A 16-item, self-report instrument was developed, the Clinical Impairment Assessment (CIA), which was designed to measure such impairment overall and in three specific domains (personal, cognitive, social). The psychometric properties of the instrument were evaluated using data collected in the context of a transdiagnostic treatment trial. The findings consistently supported the utility of the instrument with the CIA being shown to have high levels of internal consistency, construct and discriminant validity, test-retest reliability, and sensitivity to change. The CIA should be of value to clinicians when assessing patients with eating disorders and their response to treatment. It should also help inform epidemiological research.
An 11-year-old girl presented with difficulty eating and weight loss after a choking incident that had occurred 14 days earlier. She had always been a selective eater, but fear of choking led her to consume only a liquid diet. A diagnosis and management decisions were made.
Food neophobia (FN) has been shown to be a strong influence on food preferences using primarily small data sets. This has limited the explanatory power of FN and the extent to which it can be related to other factors that influence food choice. To address these limitations, we collected Food Neophobia Scale data from 1167 adults from New Zealand over a 45-month period. Participants also completed a 112-item food preference questionnaire and a self-report 24°hour, a 145 item food intake recall survey, and the Food Choice Questionnaire (FCQ). As a way of providing a structure to the food intake and preference data, in each case the food items were condensed into patterns described in terms of the foods/beverages with highest factor loadings. We then determined the impact of season and participant age, gender, education and income on these factors, as well as the interaction of these variables with FN scores, divided into tertiles. FN was a strong influence on both intake frequency and preferences in the majority of the intake/preference factor patterns. When significant associations with FN were established, both frequency of intake and preference was lower among high FN individuals. Notably, the effect of FN on food preferences was evident on many commonplace foods making up the diet, suggesting that high FN individuals like food overall less than do those with lower degrees of FN. Seasonal effects in food intake were demonstrated, but with smaller impact for higher levels of FN. While associations between FN varied according to all demographic variables, these relationships varied as a function of the intake/preference patterns. Overall, the results suggest that FN is an important barrier to dietary change and addressing diet-related health problems.
The current study describes a combined behavioral and cognitive–behavioral treatment with an adolescent boy diagnosed with avoidant/restrictive food intake disorder. Treatment included a clinic and an in-home component to increase his consumption of nonpreferred foods and eliminate feeding-associated anxiety. The behavioral treatment components included gradually increasing feeding demands and reinforcing consumption. Through cognitive–behavioral therapy, the boy was taught to use a relaxation procedure, guided imagery, and positive self-statements during meals. Results of changing criterion and multiple baseline designs indicated that treatment improved consumption of previously avoided foods and lowered subjectively perceived anxiety. These findings were maintained posttreatment, and both the participant and his mother rated the procedures and outcome favorably. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
A brief multidimensional measure of adult picky eating (PE) behavior was developed using a large U.S. adult sample. In addition, the study explored associations between specific aspects of adult PE behavior and psychosocial impairment in effort to support the inclusion of adults in the () avoidant-restrictive food intake disorder (ARFID). The study included 3 phases of qualitative and quantitative data collection. Participants were 1,663 U.S. adults who completed online surveys. Exploratory and confirmatory factor analyses were used to develop PE subscales. Associations among the PE subscales and measures of psychosocial impairment were examined. Exploratory and confirmatory factor analysis supported a 16-item 4-factor model of adult PE that included subscales of meal presentation, food variety, meal disengagement, and taste aversion. The measure also demonstrated convergence with previous measures of PE. The meal disengagement and meal presentation subscales demonstrated significant associations with social eating anxiety, anxiety sensitivity, eating related quality of life (QOL), and psychological flexibility. Meal disengagement alone was significantly associated with depressive symptoms. The Adult Picky Eating Questionnaire (APEQ) demonstrated sound psychometric properties and may be used to further investigate adult PE behavior. The relationships between adult PE and psychological impairment, particularly social anxiety, support the inclusion of ARFID in the . (PsycINFO Database Record
Objective:
To assess and compare clinical symptoms and psychometric analysis of adult patients with avoidant/restrictive food intake disorder (ARFID) with those with anorexia nervosa (AN).
Method:
We completed a retrospective review of adult patients with a feeding and eating disorder assessed between 1990 and 2005 that qualified for a diagnosis of ARFID. Patients with ARFID were compared with those with AN, with respect to the demographics, clinical symptoms and psychometric analysis.
Results:
Using the criteria of the fifth edition of the Diagnostic and Statistical Manual, 95 (9.2%) of 1029 patients with a feeding and eating disorder met the criteria for ARFID. All patients with ARFID were women. The ARFID group had a significantly shorter duration of illness, lower rates of hospital admission history and less severe psychopathology than the AN group.
Conclusions:
Adult patients with ARFID in this study were clinically distinct from those with AN and somewhat different from paediatric patients with ARFID in previous studies. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
Avoidant/restrictive food intake disorder (ARFID) is a diagnosis in diagnostic and statistical manual of mental disorders-5 (DSM-5) manifested by persistent failure to meet nutritional and/or energy needs. Pudendal nerve entrapment (PNE) often causes pelvic discomfort in addition to constipation and painful bowel movements. Current literature on ARFID is sparse and focuses on the pediatric and adolescent population. No association between PNE and ARFID has been described. We present a case of ARFID in an adult male with PNE resulting from subsequent scarring from testicular cancer surgery. The patient's gastrointestinal symptoms due to PNE caused significant food avoidance and restriction subsequently leading to severe malnourishment. Clinicians should be aware that distressing gastrointestinal symptoms arising from a secondary disease process such as PNE might lead to dietary restriction and food aversion. More research is needed for proper screening, detection, and treatment of ARFID. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016).
Picky eating is a childhood behavior that vexes many parents and is a symptom in the newer diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) in adults. Pressure to eat, a parental controlling feeding practice aimed at encouraging a child to eat more, is associated with picky eating and a number of other childhood eating concerns. Low intuitive eating, an insensitivity to internal hunger and satiety cues, is also associated with a number of problem eating behaviors in adulthood. Whether picky eating and pressure to eat are predictive of young adult eating behavior is relatively unstudied. Current adult intuitive eating and disordered eating behaviors were self-reported by 170 college students, along with childhood picky eating and pressure through retrospective self- and parent reports. Hierarchical regression analyses revealed that childhood parental pressure to eat, but not picky eating, predicted intuitive eating and disordered eating symptoms in college students. These findings suggest that parental pressure in childhood is associated with problematic eating patterns in young adulthood. Additional research is needed to understand the extent to which parental pressure is a reaction to or perhaps compounds the development of problematic eating behavior.
We examined the clinical significance of moderate and severe selective eating (SE). Two levels of SE were examined in relation to concurrent psychiatric symptoms and as a risk factor for the emergence of later psychiatric symptoms. Findings are intended to guide health care providers to recognize when SE is a problem worthy of intervention.
A population cohort sample of 917 children aged 24 to 71 months and designated caregivers were recruited via primary care practices at a major medical center in the Southeast as part of an epidemiologic study of preschool anxiety. Caregivers were administered structured diagnostic interviews (the Preschool Age Psychiatric Assessment) regarding the child's eating and related self-regulatory capacities, psychiatric symptoms, functioning, and home environment variables. A subset of 188 dyads were assessed a second time ∼24.7 months from the initial assessment.
Both moderate and severe levels of SE were associated with psychopathological symptoms (anxiety, depression, attention-deficit/hyperactivity disorder) both concurrently and prospectively. However, the severity of psychopathological symptoms worsened as SE became more severe. Impairment in family functioning was reported at both levels of SE, as was sensory sensitivity in domains outside of food and the experience of food aversion.
Findings suggest that health care providers should intervene at even moderate levels of SE. SE associated with impairment in function should now be diagnosed as avoidant/restrictive food intake disorder, an eating disorder that encapsulates maladaptive food restriction, which is new to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Copyright © 2015 by the American Academy of Pediatrics.
Background
Children's picky eating behaviour has been linked both to being overweight and underweight. However, the role of parenting practices in this relationship has rarely been investigated. The present study aimed to clarify the direction of the association between picky eating and weight status and to examine the moderating role of food parenting practices.Methods
The present study comprised a longitudinal study on the effects of picky eating on child weight status within the KOALA Birth Cohort Study, the Netherlands. Mothers and their children were included in the analyses. Children's picky eating behaviour and food parenting practices were assessed at baseline (child age 5 years). Their weight status was assessed repeatedly until age 9 years. Mixed effects linear and logistic regressions were used to compare picky eaters (n = 403) and non-picky eaters (n = 621) on changes in weight status over the years.ResultsAt baseline of age 5 years, picky eaters were slightly shorter, more often underweight and less often overweight than non-picky eaters, whereas energy intake in relation to body weight (kJ kg−1) was similar. Picky eaters with a normal weight at baseline had no increased risk of becoming underweight during follow-up until age 9 years, and were less likely to become overweight compared to non-picky eaters. There were no interactions with food parenting practices. The parents of picky eaters more often reported pressuring their child to eat and restrict unhealthy food intake compared to parents of non-picky eaters.Conclusions
The association between picky eating and child weight status was not influenced by parenting practices.
