Adult picky eaters with symptoms of avoidant/restrictive food intake disorder: comparable distress and comorbidity but different eating behaviors compared to those with disordered eating symptoms

Abstract

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.

Impact of expanded diagnostic criteria for avoidant/restrictive food intake disorder on clinical comparisons with anorexia nervosa

“…Thus, in our study, both groups reported food avoidance, but those with ARFID reported even more difficulty trying new foods than those with AN, representing the only scale endorsed more strongly by those with ARFID than those with AN. This pattern replicates findings from an online community sample in which adults with normative eating behaviors reported lower scores on the FNS than those with eating disorder attitudes but adults with both selective eating and ARFID symptoms showed the highest scores on the FNS (Zickgraf et al, ). Notably, we found no differences between the groups in endorsement of dietary restriction on the EPSI Restriction subscale.…”

“…Moreover, in this sample a subset of patients were referred for an eating disorder evaluation by other medical providers because of irregular eating habits and associated risks and/or medical sequelae and others were self‐referred due to distress associated with their symptoms. Using a modified version of the CIA that excludes thoughts about weight, shape, eating, and exercise (Wildes, Zucker, & Marcus, ), adults from an online community sample, who identified as picky eaters and endorsed ARFID symptoms, reported equivalent levels of impairment from eating behaviors as adults who endorsed traditional eating pathology (i.e., concern about weight, shape, and eating; Zickgraf et al, ). Given these findings and knowledge of our sample, we cannot conclude that individuals with ARFID have lower levels of life impairment associated with their eating behaviors than individuals with AN or lack insight into their symptoms.…”

“…It is prudent to fill the gaps in our understanding of ARFID because there is a current proposal to alter the DSM‐5 ARFID diagnosis by removing the phase in the stem of criterion A which stipulates that the eating or feeding disturbance “manifests as a persistent failure to meet appropriate nutritional and/or energy needs” (American Psychiatric Association, ). In support of this proposal, prior classification schemes for childhood feeding disorders clearly identified children with selective eating and food neophobia who were not low weight or nutritionally deficient (Bryant‐Waugh et al, ) and recent research suggests that selective eating in adults can be associated with significant psychosocial impairment (Zickgraf et al, ). It is, therefore, imperative to explore how a more inclusive definition of ARFID compares to AN to help inform how the proposed revision may impact the presentation of and impairment from restrictive eating disorders.…”

“…Similarly, the few studies that have explored self‐reported mood and anxiety symptoms in those with ARFID have found that individuals with ARFID may be less likely to endorse depressive symptoms than anxiety symptoms (Cooney et al, ; Nicely et al, ). There are currently no self‐report data on anxiety and depressive symptoms in adults with ARFID; however, there is some data on the relationship between ARFID symptoms and mood disturbances in adult community samples (Zickgraf, Franklin, & Rozin, ). Adults who self‐identified as picky eaters and endorsed at least one consequence of their picky eating (e.g., weight loss, nutritional deficiency, reliance on nutritional supplements, or psychosocial impairment in work or with family/friends) endorsed comparable levels of internalizing distress (i.e., level of negative emotions experienced) as adults who reported symptoms consistent with traditional eating disorders (Zickgraf et al, ).…”

“…There are currently no self‐report data on anxiety and depressive symptoms in adults with ARFID; however, there is some data on the relationship between ARFID symptoms and mood disturbances in adult community samples (Zickgraf, Franklin, & Rozin, ). Adults who self‐identified as picky eaters and endorsed at least one consequence of their picky eating (e.g., weight loss, nutritional deficiency, reliance on nutritional supplements, or psychosocial impairment in work or with family/friends) endorsed comparable levels of internalizing distress (i.e., level of negative emotions experienced) as adults who reported symptoms consistent with traditional eating disorders (Zickgraf et al, ). Additional research is needed to determine if observed differences in anxiety and depression symptoms between individual diagnosed with ARFID or AN are evident across ages and eating‐disorder severity to better explain clinical impairment associated with ARFID and aid in differential diagnosis.…”