ARFID: What It Is and Why It's Not Just Picky Eating

Is extreme picky eating actually a life-threatening eating disorder? In this episode of RECOVERable, host Terry McGuire sits down with psychiatrist Dr. Brad Smith to break down Avoidant Restrictive Food Intake Disorder (ARFID).

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Avoidant Restrictive Food Intake Disorder (ARFID) is far more than selective eating—it is a complex, recognized mental health condition that goes well beyond simple food preferences. Unlike anorexia nervosa or bulimia nervosa, ARFID is not driven by body image, weight loss, or body size concerns. Instead, it stems from severe sensory sensitivities to food textures and smells, aversive trauma responses following a traumatic choking or vomiting episode, or a total lack of appetite and interest in eating.

In this comprehensive guide, Dr. Brad Smith, an expert psychiatrist and medical leader at The Emily Program, clears up pervasive myths surrounding restrictive eating disorders. He explores the medical consequences of malnutrition, including severe cardiac arrhythmia, digestive slowdown, and brain fog, as well as the deep emotional and social isolation that living with food anxiety creates. We also examine the strong co-occurrence between ARFID, neurodivergence, Autism Spectrum Disorder (ASD), and ADHD.

Learn how medical professionals diagnose ARFID, why multivitamins are not a substitute for complete food nutrition, when higher levels of care or an NG feeding tube become essential tools for medical stabilization, and how exposure therapy with response prevention (ERP) helps patients safely expand their diet. Whether you are a parent wondering if your child's picky eating has crossed the line, or an adult navigating severe food aversion, this episode provides actionable clarity and hope for full recovery. Subscribe to RECOVERable for more insights on mental health, addiction, and recovery support.

Chapters: 00:00 – Intro: ARFID Myths vs. Facts

07:33 – What Is ARFID (Avoidant Restrictive Food Intake Disorder)?

08:52 – What Drives ARFID: Sensory, Trauma, & Low Appetite

12:51 – Is ARFID Just Extreme Picky Eating?

16:01 – When Do People Seek Treatment for ARFID?

20:12 – Physical, Emotional, & Social Impacts of ARFID

33:46 – What Is the Link Between ARFID, Autism, & ADHD? 

36:31 – How Serious Is ARFID & Can It Be Fatal? 

40:48 – When Is an NG Feeding Tube Necessary? 

51:26 – What Does Professional ARFID Treatment Look Like?

Questions the Video Answers:

1. What is Avoidant Restrictive Food Intake Disorder (ARFID)?
2. What is the difference between picky eating and ARFID?
3. What are the three main types or driving factors of ARFID?
4. Can adults develop ARFID or does it only affect children?
5. Is ARFID caused by gentle parenting or spoiling a child?
6. Do you have to be underweight to be diagnosed with ARFID?
7. What physical health risks and heart complications are associated with ARFID?
8. What is the connection between ARFID, Autism Spectrum Disorder, and ADHD?
9. Does a child having ARFID mean they are automatically autistic?
10. Can ARFID be fatal if left untreated?
11. How does an NG feeding tube help in severe ARFID recovery?
12. Can taking multivitamins cure or treat ARFID?
13. How do medical clinicians diagnose ARFID?
14. What is the difference between ARFID and Anorexia Nervosa?
15. What therapy methods (like ERP) are used to treat ARFID?

#ARFID #EatingDisorders #MentalHealth

Transcript

SPEAKER_02 0:13

RFID is an eating disorder where individuals start to restrict what they're eating to the point that their body is lacking the normal nutrition that it needs. It's not driven by body image concerns.

SPEAKER_00 0:24

Think RFID is just picky eating? Think again. Psychiatrist Dr. Brad Smith joins us to pull back the curtain on this widely misunderstood eating disorder. What are the emotional consequences of living with ARFID or avoidant restrictive food intake disorder? Welcome to Recoverable. I'm your host, Terry McGuire. When you think of eating disorders, odds are good you think of bulimia, anorexia, maybe binge eating disorder. Those are sort of the big three. And we've explored all of them in a previous episode that I encourage you to check out if you're interested. Today and next week, we'll be talking about two lesser-known but important to understand eating disorders that both challenge the assumption that restrictive eating is always about weight loss. Dr. Brad Smith, an expert in eating disorders, joins us today to discuss avoidant restrictive food intake disorder or RFID. And next week we'll be talking about orthorexia. Dr. Smith, welcome. Good morning. Thank you. I'm glad you know so much about these because I think a lot of people, including myself, do not know much about them. So I'm looking forward to learning from you. We're going to start with the myth versus fact. There are just 10 of them. All right. And we'll go through them quickly and then we'll get into some more depth into the other questions. So myth or fact. Someone with RFID gets hungry enough, they will eventually eat.

SPEAKER_02 1:49

Myth. Just probably it's not going to happen. It's not the way it works. It's more severe than that.

SPEAKER_00 1:54

And myth or fact. RFID is just the result of gentle parenting or spoiling someone.

SPEAKER_02 2:00

Myth. You know, RFID is an eating disorder that has a wide variety of factors as to how someone develops it. And it's not as simple as someone having a parent that was letting them eat what they wanted. That would probably be easier to treat. That would be much easier. Yes.

SPEAKER_00 2:15

Myth or fact. You have to be underweight to have RFID.

SPEAKER_02 2:19

Interesting concept here. It's a myth. And the term underweight is a loaded term in the eating disorder world. If we're talking about underweight referring to being less than your normal weight, then yes, it usually means that you're malnourished or that you have lost weight or nutrition problems from the eating disorder. But underweight uh doesn't mean that somebody has a specific numeric BMI value that's under a certain point. It's about how they are relative to where their body has usually lived. It's not about body size.

SPEAKER_00 2:52

Right. Myth or fact. With RFID, safe foods can suddenly become unsafe overnight. Fact.

SPEAKER_02 3:00

You know, some of the forms of RFID relate to people developing traumatic experiences around eating. And so that can happen at any point in life. So an adult can develop RFID after a traumatic event involving eating. So fact. It can happen all of a sudden.

SPEAKER_00 3:14

And when you say traumatic event, are you thinking is that mostly like choking kinds of things?

SPEAKER_02 3:18

Correct. Choking or intractable vomiting or something that is a very awful experience for the person and leads to this these sort of symptoms later.

SPEAKER_00 3:27

We'll get into that, I'm sure.

SPEAKER_02 3:29

I'm sure.

SPEAKER_00 3:29

Myth or fact. ARPID is just anorexia without body image issues.

SPEAKER_02 3:33

Aaron Powell Myth. These are very distinct disorders, and there's also perhaps a little bit more overlap than might be appreciated, but they are very different. And it's not just about the fact that there's literally no body image issues in RPID. There are other features that make it distinct. Anorexia nervosa has a lot of layers to it that uh are not just about body image.

SPEAKER_00 3:56

Myth or fact. ARPID is just a phase and they'll grow out of it.

SPEAKER_02 4:00

Myth. The so-called picky eating. Um, that could be common in kids or adolescents. Kids might grow out of that. Uh, we have not seen a lot of evidence that people grow out of RFID. If they develop the full constellation of symptoms and behaviors, not likely that they're going to grow out of it.

SPEAKER_00 4:18

That's sad. Yeah.

unknown 4:20

Yeah.

SPEAKER_02 4:20

Without treatment, you mean without treatment. So with treatment, they can definitely recover and you know have a fulfilling life around food and normalize their eating. But um, without treatment, it's not something that just goes away.

SPEAKER_00 4:33

Myth or fact. With RFID force feeding or the one bite rule makes it worse.

SPEAKER_02 4:39

Likely fact. Um, which is strange because some of the treatment involved in RFID is about exposing somebody to these very acts of eating in a progressive way. But with the just a one-time just take one bite, it's probably going to lead to a flooding experience or where somebody gets overwhelmed with that and then gets more fear about trying it again. So it's an important concept when going to treatment because there will be exposures to those very actions, but it will be through a progressive fashion, not just a one-time take one bite. And in a controlled environment. Right. With support with professionals that, you know, are working them through it.

SPEAKER_00 5:19

Myth or fact, RFID only happens to people with autism.

SPEAKER_02 5:22

Myth. Well, certainly it is a disease, it's an illness that affects a lot of people with autism. And there's a higher proportion of people with autism spectrum disorder that uh end up developing RFID. And so it's common among uh those with RFID, it's common to find that they may have uh autism spectrum disorder, but it is certainly not the only correlation with RFID. There are many people without autism spectrum disorder who have RFID.

SPEAKER_00 5:49

This is one that's all over the internet. Myth or fact, multivitamins are a total cheat code for RFID.

SPEAKER_02 5:57

Myth. It's a very important one because even in treatment centers, you might find that multivitamins are used kind of to cover all the grounds. Uh, you know, we we want to make sure that people have their uh micronutrients and their vitamins. Um, and so oftentimes, even in treatment centers, we'll use multivitamins, but it's not to replace food and it's not to replace the normal nutrition that someone needs. So if someone is doing that on their own, it's not going to cover them or allow them to continue doing what they're doing with the regular food. It just provides a little bit of insurance against the micronutrients or the vitamins and minerals that their body might be missing.

SPEAKER_00 6:39

Myth or fact. Recovery from APID means that eventually they'll eat everything.

SPEAKER_02 6:44

Myth. We certainly hope that they'll eat a lot more variety, but they may not eat everything. They may still have significant challenges with some extremes of those challenges. And we can consider them in full recovery because they have a fairly normal variety of food intake and fairly normal way of eating with uh friends, family, and um loved ones.

SPEAKER_00 7:06

And is it about getting the nutrients your body needs to function?

SPEAKER_02 7:10

Correct. Yeah. And and to function normal socially. You know, food is such a big part of our cultural norms and our the way that we share time with friends and family. And so one of the components of RFIT is that it starts to impair that functioning because people get too scared to go out to eat with friends or family, or to go out to eat at all, or to share a meal even at home.

SPEAKER_00 7:32

See, I jumped right into follow-up questions because I want to learn about this. That was supposed to be the short part. Okay. First internet question, and this is the most commonly searched across all the platforms. This was Google, TikTok, YouTube, everything. The basic one. What is RFID?

SPEAKER_02 7:47

RFID is an eating disorder where individuals start to restrict what they're eating to the point that their body is lacking the normal nutrition that it needs. And it we touched on this a little earlier. It's not driven by body image concerns. It may be driven by several other factors, but it's not driven by body image concerns. Why is that distinction important? Well, because most of the eating disorders that are more common in our society or that more people learn about are driven by body image concerns or body image fears. And that's an important distinction if you're somebody who has RFID, and it's an important distinction if you're having if you're taking care of someone with RFID.

SPEAKER_00 8:28

I suppose we should define what RFID stands for.

SPEAKER_02 8:31

Yes. Avoidant restrictive food intake disorder.

SPEAKER_00 8:35

And how how common is it?

SPEAKER_02 8:37

You know, I don't know that we have great estimates because it's relatively new in its definition and understanding. Now, it may not sound new when I say how long we've had the definition. We found it in the DSM five version. So that dates back to about 2013. And before that, it was considered part of more of a feeding disorder of infancy and childhood. So the concept has been around a long time. So what are the driving factors of RFID? One type is where people have extreme sensitivity to textures or tastes. So it's more about a sensory sensitivity. So that's one of the driving factors or categories.

SPEAKER_00 9:18

And we're not talking about I don't like tapioca. It's more than that.

SPEAKER_02 9:22

Correct. It's like I may have a panic attack because I have tapioca in my mouth, and that texture is so disgusting to me that I may have a panic attack. It's that level of anxiety around it. Another driving factor could be a fear of some sort of aversive consequence of eating. So this encompasses people who have had problems with choking, or they may have had problems with intractable vomiting at some point in their life, or some sort of disgusting taste that has led them to have this extreme fear that they're going to experience that same reaction again. So kind of this aversive consequence fear. I don't know what intractable means. It means it can't stop. Oh. Which is not common, of course. And what, you know, we might experience that in a 24-hour GI bug and might get to the point where we're having, you know, maybe one round of, you know, couple, several times where we're vomiting and it feels like it's not going to stop, but it stops. And then you have other occasions where somebody might continue on or have a very severe case of GI bug where they're doing that multiple, multiple times a day and it can go on. And then after that, they have this extreme fear of eating. It's actually a trauma. Right. And the third? Third type is probably what I think our field understands maybe the least of the three kind of categories, and that's of uh just not having a drive to eat. And this often is more in childhood, adolescence, where you see um kids with feeding disorders or where they've struggled with feeding as an infant or newborn. And into their life, they're they develop this extreme pickiness. And then as they get even to adult life, they're still not having a strong drive to to eat. Um and, you know, there are a myriad of possibilities here, and it's not well studied yet. Uh, but you know, we we have basic drives to eat that exist in our brain, and uh there are likely factors that are not working quite right there. And then you also have um situations where people might not have a drive to eat for other psychiatric illness or other medical illnesses where they just don't get hungry or just don't think about eating, or they don't slow down enough to eat.

SPEAKER_00 11:39

So is it disinterest in food? Is it low appetite?

SPEAKER_02 11:42

All of the above. Um, and again, it's at least in my practice, it's been the least common of these three categories. And I think also because when somebody has that absence of drive to eat, people usually are still thinking it's some other medical issue or some other psychiatric issue. And so they're not necessarily presenting for eating disorder treatment to address it. It does exist, um, and it's not as well defined or as as well appreciated, but it is that third kind of main category or bucket of types of RFID.

SPEAKER_00 12:16

So are there people with RFID who want to eat more, but don't or can't?

SPEAKER_02 12:21

Absolutely. That's one of the that's one of the great things about the success of treatment for people with RFID, is that many times, especially in those other two buckets, um, people want to get better. They want to be able to eat normally, both because they might recognize that they're malnourished, their body has suffered because of their eating patterns, and also because it's impacted their functioning. They want to be able to sit down at a meal with family, they want to be able to go out to eat with friends. And so there's a strong drive to try to get treatment or help for it.

SPEAKER_00 12:54

You've touched on this in other answers, but this again is Google, YouTube, TikTok across the board being asked, is RFID just picky eating?

SPEAKER_02 13:04

No. And, you know, picky eating is common, and especially, you know, kids and adolescents. And, you know, I think back to my own childhood and adolescence, I was a lot pickier eater then than I am now. And tastes develop and mature over time. But picky eating is um, if you think of picky eating to like an exponential extreme, would be more of what RFID is. Um it's that take and hold to the point where people really have a very difficult time, almost to the point of being impossible to really reverse that trend of of how restrictive they've become.

SPEAKER_00 13:39

Are we talking about having, I don't know what what number to say here? 10, 20 things that you'll eat?

SPEAKER_02 13:47

Less. Oh. Some I've had people come into treatment where they may be down to three or four things that they'll eat.

SPEAKER_00 13:53

Wow.

SPEAKER_02 13:53

And um, so very restrictive on the types of foods that that will be consumed. And as you can imagine, very difficult to then nourish yourself if that's all that you're able or you know, able to consume at that time.

SPEAKER_00 14:08

And again, it's not a food preference, it's a belief that the other foods are what, dangerous?

SPEAKER_02 14:14

Could be dangerous. Certainly in the case of um, you know, people who worry about adverse consequences. It could be um, you know, enmeshed with an OCD pattern where there's a fear of contamination with the food, or it could be a fear that the food is going to do something to them. For instance, um, you know, if their choking episode or episodes have occurred primarily with things of more of a normal consistency, meats or uh fruits or something that isn't really, you know, soft, um, they may have restricted down to just drinking things like insure or boost or drinking shakes and not really able to um expand beyond that. And that the fear that is about the consistency of the food will cause them to choke again or could have some sort of major adverse event.

SPEAKER_00 15:09

So something in their mind as a result of the previous episode just tells them this is dangerous for you to do, avoid it.

SPEAKER_02 15:17

Right. Very much like a trauma response. So, you know, I know I've probably had episodes on trauma responses and PTSD, and um, and that is that is very similar to what we see here, whether it's the choking, maybe not a full episode of choking, but maybe they have some sort of um trouble with their mechanism of swallowing, and so they're at risk or fear of of choking at some point because it's different than what they were experiencing previously. So a lot of times where there's a medical issue that has caused a change in their swallowing, uh, or if they've had a choking episode, um, and then the vomiting, of course, can be after some sort of GI bug, but it is very much a trauma type response.

SPEAKER_00 15:59

So in an eating disorder treatment facility like you oversee, when do people usually come for help? How how bad does it have to get before someone says, I think this is really a problem? And do they make that call themselves, or does somebody say you need help?

SPEAKER_02 16:15

Well, it's it can be either. But um, you know, in RFID, unfortunately, because it's a little bit newer in terms of recognition and diagnostic clarity, it perhaps goes a less notice than, say, anorexia nervosa or bulimia nervosa. I'd say the most common reason it comes to attention is because there's been significant weight loss or malnutrition that's become evident from a medical standpoint. People can see it. The individual might be experiencing it all the way from noticing the change in their body size to noticing, you know, some of the common features of malnutrition, like brain fog, not being able to think clearly, uh, fatigue, not being able to do their normal activities. Um, so it's usually when there's some sort of consequence that interrupts their functioning or their thinking that you know will cause the individual to come to someone's attention. And in other cases where it's family members or loved ones that might notice it's more typically because of the physical appearance, has become concerning to others. And then, you know, the medical community has understood and recognized RFID, but it's still relatively new. So they may be seeking help from their normal caregivers who might not be as familiar with RFID. So there may be delays in people getting treatment that would be laser focused on how to help them with this.

SPEAKER_00 17:38

Yeah, I'll bet. There's enough things that are missed, and I don't mean to disrespect the medical community, but you know, a primary care physician can't be expected to know everything and clearly does not.

SPEAKER_02 17:47

I I so appreciate that you phrased it that way because I I think back to medical school and how so often, you know, in the you know, in the ivory tower of the medical school, there there would be, you know, cases of individuals who had you know come in from a local small town ER that you know that that there was there were critiques about how they had managed the situation. And in my mind, I was always thinking there were probably 999 other patients who walked in the door with those same symptoms who did not have this kind of unusual case. And um, and so it's a lot to ask for primary care providers to be familiar with everything and and anything. Um, so RFIT is just one of those that's a little bit newer on the scene and a little bit harder for people to recognize because it it hasn't been around as long.

SPEAKER_00 18:37

I was saying that we currently have a an eating disorder episode of this podcast out, and the comments that were coming just last night were doctors don't know, doctors don't know, and that there's very little actual training. And one person who went back and forth with me in the comments said that he's currently studying psychiatry and that the I think it was a 30-minute uh lesson on eating disorders. And he said, How can things get better if people aren't being trained to recognize and treat them? Is that something you see?

SPEAKER_02 19:10

Yes. I and it's an it's a critique that is well founded. It's not surprising to hear, I presume a psychiatry resident, that they may not have um anything dedicated specifically to eating disorders. And, you know, I had some exposure to eating disorders in my training. It was more happenstance than by design. Um, it just happened to be a summer internship between my first and second year of medical school where one of the assignments was to, you know, shadow and work at one of the local hospitals that had eating disorder units. Um, but it's not a it's not necessarily a strong part of training in medical school or residency programs. Um, it is, you know, one of the many, many required topics, but it may be, you know, a lecture or two on um on this. And, you know, that's one of the things I hope to continue to contribute to the field. It's helping to train more people, whether it's through nurse practitioner preceptorships or whether it's through residency rotations. Um, there's a lot of room for improvement in terms of exposure to eating disorders for the medical field.

SPEAKER_00 20:16

So you are familiar with the treatment of eating disorders, and that is your job. Can you explain the physical, emotional, and social impacts of RFID?

SPEAKER_02 20:25

Uh the physical consequences of RFID are going to look very similar to the physical consequences of other restrictive eating disorders. So, like anorexia nervosa, whether that's restricting type or binge purge type, but restriction of food intake and unintended weight loss can lead to malnutrition where somebody doesn't have the macronutrients that they need in the right balance, and they don't have the micronutrients like vitamins and minerals that they need in the right balance. So these things cause a plethora of problems in the body. What we hear about most commonly, and the the most common cause of death for people with malnutrition, uh, tends to be cardiac related. So these micronutrient vitamin mineral changes, the electrolyte changes will lead to the heart having trouble keeping a regular rhythm, slowing down and then having trouble with a regular rhythm to the point that somebody's at risk for an arrhythmia and a sudden cardiac death. So the cardiac system takes a big hit. When with longer-term malnutrition, the muscles of the heart become weaker and weaker as well. So a lot of problems take place because of the effects on the heart and the and the cardiovascular system. The other main area is the GI system. And so the restriction of food intake can cause the GI system to continue to slow down. You know, it if it doesn't have much going through, it doesn't have a, you know, reason to keep pushing things through.

SPEAKER_01 21:59

Yeah.

SPEAKER_02 22:00

So the stomach starts to take longer to empty into the intestines. The intestines take longer to move things through. And so what might might be as simple as some mild constipation can turn into a complete bowel obstruction. So the GI system, the cardiac system, and then the central nervous system. We talked about the brain fog that can happen with malnutrition. It's a very real experience for people who get malnourished. And so the central nervous system is affected by the attention and concentration. It can also be affected through seizures or coma and major electrolyte disturbances that can induce those sort of things.

SPEAKER_00 22:40

It's really serious.

SPEAKER_02 22:41

It's extremely serious. One of the sobering experiences I had with one of my very first media interviews around eating disorders, way back probably about 15 years ago now, was part of Eating Disorder Awareness Week. And I gave what I thought was a great, you know, exchange on the awareness of eating disorders and how treatable they are, because many people mistake mistakenly think that eating disorders are not treatable. And I received a communication after that media uh aired, and it was a mother of a person who had died from their eating disorder. And she, you know, gave me some critiques about that interview that I hadn't been uh highlighting how dangerous the eating disorders were. And I knew that, of course, I knew how dangerous they are. Um, but I had failed to convey that to the audience. And that's a very important part that audience members need to know. So I try to make sure I include that in any, you know, interview that I have or media uh opportunity that I have, that these are life-threatening illnesses and they are um illnesses that unfortunately are often cited as either the leading cause or the second leading cause of death among people, among any of the mental health issues. Um so they they cause extreme physical problems and they can cause death.

SPEAKER_00 24:03

So while in that interview you didn't uh adequately address the risks, I want to make sure that in this one you also communicate that with treatment there is hope and the possibility of recovery.

SPEAKER_02 24:16

Absolutely. Unfortunately, we're still talking about, you know, a small percentage when looking at the all the people who come in for treatment or all the people who have these disorders that end up having that such a bad outcome. Um, but treatment is effective, treatment can lead to recovery. And so there is hope, there is reason to come in for treatment. Um, but one of the messages is that we want to have people come in for treatment because these are dangerous illnesses.

SPEAKER_00 24:47

So that was the physical. Let's shift to the emotional. What are the emotional consequences of living with ARFID or avoidant restrictive food intake disorder?

SPEAKER_02 24:57

Yes, and this gets to be a tough one because it we're a little bit with the chicken and the egg phenomenon here. So I'll start with, you know, presuming that something occurs as a consequence of the RFID. So people living with RFID are likely to um start to experience more isolation because they no longer tend to avail themselves to going out with friends where food is going to be involved. They might not be getting together with family for meals, and that's where a lot of our social interactions happen. So they may start to experience isolation, depression, and they may be experiencing those physical consequences like fatigue and concentration start to take a toll emotionally when people start to get down, they get depressed that they're not functioning the way that they normally function. And um their relationships get impaired by these same sort of phenomena. So emotionally, it can take a toll as a consequence of the RFID. And then, you know, if we look at the other side of the chicken and the egg phenomenon, it many people with RFID, it's been related to some other mental health issue or emotional issue that overlaps with RFID or affects their eating, which has now led to this, you know, extreme eating disorder.

SPEAKER_00 26:16

You pretty much brought the social one in, so I won't separate that out. What are the most common mental health conditions that overlap with RFID?

SPEAKER_02 26:23

Uh we talked about autism spectrum disorder. So we're about to a neurodivergence. Um we also see a lot of people with OCD and severe anxiety disorders, which, you know, if you take away the DSM criteria and you really step back from like the 30,000-foot view and try to think about, you know, the symptoms, the behaviors, and how how common the language is around that, it's it's easy to kind of see how OCD and anxiety disorders overlap so much with ARFID and have such co-occurrence. Um to a lesser extent, depression, uh, trauma, uh, as we talked about, there's a trauma-like response that can lead to these fears of the aversive consequences.

SPEAKER_00 27:11

So who gets RFID? Is it just kids or can adults get it as well?

SPEAKER_02 27:16

Anyone can, fortunately. Um we hear about it probably more in kids. Um, there's, you know, more attention typically on whether kids are eating, you know, the variety of foods that they need. Um, and rightfully so, because we have in our lives, we have a window of opportunity for normal growth and development. And so that's why so much of our well-child exams and and all of the wellness exams throughout childhood and adolescence are looking at what is the nutrition like for the for the child? What does the growth curve look like? Are they tracking? We start to see changes or abnormalities there, it's brought to someone's attention more than it would be for an adult. Adults more commonly see fluctuations, variation that um aren't tracked as closely either by them or for their healthcare providers. Uh, but people can develop RFIT at any age. Um, and it doesn't have any barriers in terms of who it can affect, so it can affect anyone, any age.

SPEAKER_00 28:21

This podcast is a production of recovery.com. Getting help for an addiction or mental health concern is one of the best decisions you will ever make. But once you make that decision, it can be tough to know what to do next. That's why we built recovery.com. It's the best place to find mental health and addiction treatment for anyone, anywhere. Here's how it works: search over 22,000 facilities, compare your options, and connect directly with treatment providers that meet your needs. So if you need treatment that goes beyond an occasional therapy session, go to recovery.com. Your recovery starts today. As a parent listening or watching, how are they supposed to know if their child has ARFID or if they are in fact just very selective eaters?

SPEAKER_02 29:11

Yeah, and there's not a distinct line of when that's crossed. So understandably there's this spectrum of picky eating to ARPID, or maybe we should start with like normal eating and then picky eating, then RPID. And there's not a well-established line. Um, but I think when we get to, you know, wanting to make the diagnosis or wanting to intervene from a treatment standpoint, we're primarily looking at is this affecting someone's, you know, nutritional level at the level of like their macronutrients, their micronutrients, are they showing signs of malnutrition that might not be picked up by just a weight change? Um and is it affecting their functioning? There's whether it's social functioning, their school or work functioning. Um, and those are those are perhaps different for different people. Um there are questionnaires and outcome measures that can be used to try to pick up where something is likely to be impactful to the point of of you know needing treatment, professional treatment. But um I think we're still learning about where that is. Um, but certainly, you know, I I see people coming into treatment where they're they're on the extreme. And, you know, perhaps you know, when when folks are wondering at home if we should get treatment, or folks are in a primary care office wondering if they should get treatment, you know, that's a little it different. There are many steps from there to a treatment center. So at a treatment center's site, we're usually seeing people with severe malnutrition problems, severe social and functional impact. Um, so it's not really a question in the folks that come in there. And I think um it's a harder call for a family or primary care office as to when the professional treatment is necessary.

SPEAKER_00 30:59

Um hearing it as a parent, hearing you talk as a parent, and I'm thinking back to when mine were young, I didn't know what their micronutrient uh intake was. I mean, I I tried to feed them well, but I I wouldn't have known if it was if I wasn't doing a good job, I don't think, unless I could see it.

SPEAKER_02 31:16

Right.

SPEAKER_00 31:16

So if I am a parent and I'm not equipped to analyze that, and if my primary care physician or their primary care physician is not not uh skilled at recognizing the symptoms of RFID, it would get pretty bad before attention would be paid to it, right?

SPEAKER_02 31:35

Perhaps. I mean, mm you know, perhaps a a primary care clinician may not distinguish that this could be RFID, but they're going to pay very close attention to growth curves, both weight and height growth curves. They're going to pay attention to lab values, they're going to pay attention to the vitals changing. So those do offer some early, fairly early signs of this. Um and, you know, I think in a lot of well-child checks, there's a lot of investigation around how the child is eating. Um, and, you know, there's there's a been a lot of attention in the pediatric world and the primary care world around, you know, people living in larger body sizes, like um, and you know, screening for obesity. Um, those are areas that people have been probably better trained in the medical world. And there's some biases associated with that, I'm sure. There is a lot of attention on the growth curves and how people's bodies are functioning. They may not be as you know precise as saying, I think this is RFID, but um, but I think, you know, I want to give credit to the primary care clinicians, they'll probably pick up that there's a nutritional issue going on here.

SPEAKER_00 32:50

So notice an eating disorder, not necessarily name it RPI.

SPEAKER_02 32:53

Right, right.

SPEAKER_00 32:54

Okay. I can live with that. And since you brought up larger bodies, we should probably also mention that you can have eating disorders, including anorexia, and live in a larger body.

SPEAKER_02 33:03

At any size, and no, no barriers, no boundaries. And it's a common misperception that people you know with eating disorders would have a certain body size. And um, we learn more and more every day about how that's not the case. And more of it is about the thoughts, the symptoms, and the impact, as well as you know, these nutritional changes um can happen at any size and any weight. And um, we certainly have had a lot more training and education around the very low BMI numbers and and the dangers with that. But um, as we continue to learn more, we're learning that people at all different sizes can have the same levels of medical consequences and risks, unfortunately, as people with very low BMIs have.

SPEAKER_00 33:51

Point worth making. So, another common internet question and search is what is the connection between RFID and autism or ADHD?

SPEAKER_02 34:00

So the connection uh I think will be an area of research that will be very fruitful um, you know, in the coming years. I think, you know, in one of those buckets that we talked about in terms of the driving factors of RFID is around sensory sensitivity. And neurodivergence is often commonly um having individuals with neurodivergence commonly have uh sensory sensitivities and as a part of that phenomenon. And so it's then understandable why they may be more prone to RFID than someone in the general population who doesn't have those sensory sensitivities and around textures, tastes, um, environments of eating can factor in. So light sensitivity, sound sensitivity, all those things can impact the experience of eating. And so people with neurodivergence tend to be more susceptible because of those types of sensitivities. And they're, you know, we will likely learn more about the areas of the brain that are involved in both of these illnesses and phenomena. But at this point in time, it's just a well-established connection and something that people look for. Like if you have someone with RFID, we might do a little bit more, you know, due diligence on looking into neurodiversity in the diagnostic profile of someone, um, even if it hadn't been diagnosed before, because especially if we start to hear about the texture or the taste sensitivities and how that's factoring into their eating problems.

SPEAKER_00 35:31

So that leads right into this question, which is all over YouTube and Google. If my kid has RFID, does that mean they're autistic?

SPEAKER_02 35:38

Understandable question, but no. It's not a direct correlation. Just because there is this, there is a high comorbidity or co-occurrence that it leads most eating disorder clinicians to investigate a little further, like even if something wasn't picked up in school or in some previous diagnostic workup, do we need to look a little farther into this? Because maybe as the at the eating disorder treatment that ensues, you you initially learned about the sensitivity to taste or to the textures. But as you work with them, especially if you have them in a 24-7 setting, you might start to appreciate they have these other things, like the sound sensitivities or the light sensitivities or touch sensitivities, where you start to investigate a little further, like this is more than just affecting their eating, this is affecting other parts of relating that we might need to investigate further.

SPEAKER_00 36:34

There were all kinds of searches. I put these two together because they're similar. Uh, how serious is RFID and can you die from RFID? There were a lot of searches for straight up can you die from RFID?

SPEAKER_02 36:45

Yes. Um, it is very serious. You can die from RFID, uh, just like you can die from any sort of restrictive eating disorder. That is also countered with the uh understanding that you can also receive great treatment and great recovery from RFID. Um, but it's important to recognize the dangerousness of these illnesses. As something like RFID has gotten more well known in the media, social media, I think it's it's becoming increasingly well known among adolescents and young adults. Um, that is great. But sometimes the more that we know about something, the less dangerous it might seem. Um, and so it is important to understand that yes, individuals can die from RFID, and it's a very serious illness.

SPEAKER_00 37:34

So you brought up social media, which is interesting because I had not heard of RFID. And as soon as I started mentioning it around the office, which is largely people who are younger than me, they all said, Oh, yeah, I see that all the time on YouTube. I see that all the time on TikTok. What does it do in the medical community when a condition becomes popular, or I don't know, I think that's the word on social media?

SPEAKER_02 37:57

Well, you know, like any form of media, it can do harm or it can do good, or somewhere in between. Um, so the great thing is I was just mentioning, a lot of people understand or have heard of RFID. So we hope that there's a lot more awareness for people to seek help if they need professional help. And with that, we also have potential harm where, you know, is it adding to, you know, people thinking about this or wondering if they should, you know, dabble in some of the behaviors in some cases, especially more you see this more in the anorexia um, you know, arm of things where there's there are influencers, there are people on social media encouraging people to engage in behaviors that would be associated with those illnesses. So we certainly have the possibility of harm, we have the possibility of great help. Um, but I the you know continued kind of discussion around food and how we're eating uh can have both negative and positive effects. So um I I I'm also cognizant that in our field of eating disorders, from my perception, you know, coming into the field of eating disorders about 15 years ago, I had worked in other fields of mental health before that. And one of the things that struck me in the field of eating disorders had been that they we had an unfortunate history of kind of looking at one or two factors as to being the you know culprit for eating disorders. As a kid, I remember, you know, the culprit being a lot of blaming of families, or, you know, that that was an over-aggressive or micromanaging family was going to result in eating disorders. Very unfortunate kind of time in history, um, because that doesn't really help the situation. It's not really accurate at all. Um, for then started to see that you know, there's a lot of blame placed on media portrayals of body, and that is a factor. Um, but these are complicated illnesses. They have genetic factors, they have predisposition factors, and they have nurture factors. They have things in our environments through our life that can make us more susceptible or that can lead us to have these predispositions come out. You know, these are things that that I try to be cautious about and to not blame social media as a sole cause or main cause for things, but we have to be cognizant of the impact. I mean, this is social media and media has a significant impact on the way we think about a lot of things, including our health, including the ways we eat. And so I'm hopeful there'll be more and more positive information and positive outcomes from the way social media is used. Um, but you know, what it does for eating disorders has um has probably leaned more towards negative than positive, unfortunately.

SPEAKER_00 40:50

So we've talked about that ERPA can be fatal. We've talked about it's a potential effect on the heart. One of the questions is can ERFA get to a point where a feeding tube is necessary and is that rare?

SPEAKER_02 41:02

It certainly can. And um, you know, feeding tubes, just for those who might not be familiar, um, are a staple of eating disorder treatment, especially at higher levels of care, like inpatient treatment or even in some residential settings where it's 24-7 treatment. Um it is it is not a starting point by any means, but it is a sign that things have gotten to the point where regular nutrition through, you know, eating through the mouth has not been working. And so a tube can be placed in a variety of ways, the most commonly being to pass a small tube that goes through the nose down into the stomach, and it's called an NG tube. And that is the most common type of feeding tube that's used in eating disorder treatment. And, you know, I don't know the exact percentage of people who end up on a feeding tube who have RFID. It's a small percentage. But in, you know, an inpatient treatment unit, for example, it may be a third to a half of people might be on a feeding tube because that's why they're in an inpatient setting. They can't eat by mouth. Um but it is uh it can be highly effective for helping people turn the corner to start getting the the nutrition that they need. Um but it is a sign that things have gotten to an extreme, uh for sure. And it can be a very necessary part of the recovery process. You know, we're talking about uh before that people can get down to three or four foods that they're willing or able to eat. And at that point, um, you know, there's some other form of nutrition that's going to be necessary for most people to start reversing the course.

SPEAKER_00 42:40

So I can imagine not wanting that. I can imagine thinking, oh, you know, a feeding tube sounds awful. I also wonder if having nutrition in your body for the first time in a while, do you see patients start to, I don't know, I'm thinking of watering a plant that was wilting. I mean, what do you see as a result in terms of their the way their mind is working, the way their body is working?

SPEAKER_02 43:03

Well, right, primarily positive effects. Um, you know, they're getting the nutrients that they've been missing. Um, so all those things, yes. And when you get to the extreme of a feeding tube, um, you know, it's another area of our field where there's been some differences of opinion about um the value of using tube feeding and and kind of having a a negative connotation um because unfortunately it's not, you know, it's not been universally accepted as, you know, as being a positive intervention for people. We certainly have had unfortunate circumstances where it hasn't been employed in the way that that people experience it in a positive way. But for the majority of people who have used feeding tubes, they cite that as a big turning point in their treatment and recovery because of getting those nutrients that they need that they wouldn't have been able to get. Uh so it's not necessarily something magical about the feeding tube itself. It's just that the nutrition can get in, and it could be significantly easier than trying to do the same thing with drinking supplements like Booster Ensure, or trying to eat regular food to nourish the body. Body. And so you do start to see some very impressive turning points for people when they get the nutrition in. And it makes it more, in many cases, more manageable then to start doing that very, very difficult work of doing the most anxiety-producing thing that you can imagine five or six times a day. And so, you know, we and I'm always humbled in working with clients with eating disorders around how difficult this is because you think about other forms of things that you have to change behavior on. And sometimes you don't have to face it on a continuous basis. But the worst fear that someone has with an eating disorder is eating that food and the experience of that. And they have to do it multiple times a day. So as a starting point and then hopefully a turning point, if we can start to get the nutrition in in a way that is not as difficult, perhaps, as that anxiety-producing event of eating food the regular way, then we can work on that behavior, that change, um, in a more controlled fashion. We can take our time in helping them continually add more food that they can eat, more volume, more variety, while we know that they're getting adequate nutrition through the NG tube, it can be a huge turning point for people.

SPEAKER_00 45:35

That's what I was asking. Not the soft, I didn't mean it as a softball, like, well, well, good things. You know, I meant does the patient, right, recognize or or experience it as a positive when it starts to have an effect. I can't imagine anybody saying, like, love this.

SPEAKER_02 45:52

It exactly. It's not something that people, you know, we worry about situations if people, you know, are wanting that. It usually means they may not have the motivation at the point or the level that they need to make important strides in recovery. But um, but it's positive from the standpoint they're they're starting to have energy again. They start to uh, you know, feel like they have hydration again and they can think clearer, they can concentrate on the therapy better, they can tackle that next meal better because they have they're starting to get the nutrition back.

SPEAKER_00 46:27

It has to be so hard to start to eat things that you truly believe are going to cause harm to you.

SPEAKER_02 46:34

Absolutely. And just gut-wrenching, also to watch people experience that, you know, and I'm not, I would I'm, you know, watching somebody or experiencing a panic attack is a fairly common phenomenon that, you know, if you're watching that happen every time somebody's trying to eat, it's just very, very difficult. Um, not to mention obviously how difficult it is for the person experiencing it. And so, you know, there are important interventions that can take place with professional-led treatment that really help people to do this because it's it is painstaking work. It's not, it's not overly complicated in terms of what needs to happen. It's just painstaking work on the part of the client as well as the treatment providers that are trying to continually chart that course with them on how to how to make it manageable. It's it's very important but very challenging work for them.

SPEAKER_00 47:33

How is RFID diagnosed?

SPEAKER_02 47:36

I think it's best diagnosed if you have the opportunity for an eating disorder professional clinician to be able to do a full assessment with someone and come to a diagnosis. There's not a there's not a litmus test, there's not a blood test, there's not um an x-ray or an imaging study. And um it's it there's not even a you know questionnaire that is going to be fully accurate. There are some outcome measure type questionnaires, patient questionnaires that can give us a better handle on kind of the severity of symptoms and behaviors, but there's not a there's not an established um cutoff line of where when it's RFID and when it's not. It's more from the professional clinician, you know, looking at the person in a holistic manner, looking at all the factors going into this, looking at those things like those outcome measures, and then trying to establish the accurate diagnosis.

SPEAKER_00 48:27

Does a psychologist, dietitian, GI specialist, who all needs to be involved to come up with uh an accurate diagnosis?

SPEAKER_02 48:38

You know, if somebody has experience or special training and certification in eating disorder treatment, it can be any of those. It could be a psychologist, could be a therapist, could be a dietitian or psychiatry provider, psychiatrist. I think knowing that they have that expertise or experience in eating disorders is going to mean that they they are going to understand RFID, they're going to understand, you know, how to make that accurate diagnosis. And when you get outside of that, it's not as it's not as clear as who that would be. It because as we talked about, there's not there's not extensive training in other fields of healthcare around this. So it would be, you know, if somebody has happened to have that sort of exposure, that sort of training that they may be more aware of eating disorders and RFIT in particular to be able to help make that diagnosis. You know, among my, you know, great colleagues, you know, around the field and and also around the country and other areas of medicine, I think, you know, GI uh specialists are are learning a lot more about eating disorders because they see so much of it. And our primary care, they continue to learn because they're seeing so much of it. And um, as people have more awareness of things like RFID or other eating disorders, they're seeking treatment. And I think they're most commonly going to a primary care clinician or ending up in a GI specialist's office because of the common consequences of it.

SPEAKER_00 50:05

What's the most common condition that RFID is mistaken for? And how can parents avoid that wrong turn?

SPEAKER_02 50:12

Uh it could be mistaken for just simple picky eating. Um, you know, it depends on the difference of opinion of how much variety you think is appropriate or normal for your child or um or loved one. And um it's commonly mistaken uh for anorexia nervosa. You know, that's a whole other topic in and of itself. And even for our eating disorder field and our specialists, there's um, you know, anorexia nervosa and um RFID have some you know common ground. They're thought to be very distinct, and most of the time they are, but they're not mutually exclusive. And so you can have you know, someone who's had a history of one then develop another. It's a very common phenomenon in eating disorders, and for lack of better terms, it's kind of it's called migration of symptoms and behaviors where people might have you know more symptoms, behaviors of um anorexia nervosa for a while. It might then develop into more of an API pattern. Um it's not the norm, but it's it's common enough that people in the field recognize that sort of possibility. Um so I think the com most common ones are going to be mistaking it for simple picky eating and mistaking it for anorexia nervosa.

SPEAKER_00 51:30

Both of which can have consequences.

SPEAKER_02 51:32

Correct.

SPEAKER_00 51:33

Yeah. So what does treatment look like for somebody with RFIT or avoidant restrictive food intake disorder?

SPEAKER_02 51:40

Treatment can look like a lot of different ways. But the, you know, in a lot of mental health treatment or psychiatric treatment, we talk about levels of care because different levels of severity require different levels of professional support. So it could look as straightforward as traditional outpatient treatment where somebody is seeing a therapist, for example, they might be seeing their primary care provider at the same time. And that's how they start treatment, especially if it's not severe at the time. Um, all the way up to, you know, you can have everything in between. You have intensive outpatient, you can have partial hospital, um, you can have residential 24-7 care, and all the way up to inpatient care. And so it looks very different depending on what level of care it is. But we think of it as the best treatment is whether it's a multidisciplinary approach, a team of professionals, um, which is part of what makes this work so humbling, is because you need your colleagues in this to help, because we're talking about you know, emotional and psychological effects. We're talking about physical effects that require nursing and more like primary care approaches, and you're talking about psychiatric illness that's common. So you need psychiatry, and then you're talking about the you know, underlying therapy that needs to be done to help individuals. So it usually looks like a multidisciplinary team when it's done well. And that treatment is often a little different than other forms of eating disorder treatment. And that's what makes this um you know important to talk about because unfortunately, um, you know, the best place for people to get treatment for RFIT is typically an eating disorder treatment center. But unfortunately, even there, they can feel like they're a fish out of water because they don't have the body image-related issues. They don't have the same psychological underpinnings to their illness as people with anorexia nervosa or bulimia nervosa have. And so the treatment, the programming in a lot of treatment centers is designed around helping people with those core features of their illness, but the people with RFID don't have those features. So there's a lot of tailoring of and individualizing of treatment that's done in the settings, but the team has to really make sure that they're addressing those core features differently than they would for somebody with anorexia or bulimia. And the type of treatment that's most common in this is addressing their fears through exposure-based work. The most common approach is called exposure with response prevention. It's a form of cognitive behavior therapy that's the gold standard treatment for OCD and severe anxieties. It's applied to their eating patterns and their food selection and their food variety in a very systematic way as a core feature of that treatment, which may not be a core feature of other forms of eating disorder treatment. Okay. But it's a lot more work on the exposure-based work, also helping them with sensory sensitivities through things like in the exposure-based realm of doing work on being more tolerant of sensory changes in the body that can happen with eating or that can happen with fullness. Um, and those are, you know, I think of those as being much more active forms of treatment. We think about other forms of mental health treatment. We think about a lot of, you know, talking therapy, individual group therapy, and um, and education, psychoeducation. But for this type of approach for people with RFID, I think of it as more active behavior change as being the focus. There's of course going to be the work on their cognitive thoughts and their patterns and their feelings, but it requires much more focus on that behavior change and helping them through that anxiety of trying the next food in a way that is challenging but manageable. And that's that's all laid out in a very nicely developed treatment plan for someone. Um, that's different than what it would look like for someone with with other forms of eating disorder.

SPEAKER_00 56:10

So someone looking for treatment should make sure that the place they're considering has specific programs for RFIT.

SPEAKER_02 56:19

At least specific individualized treatment for people with RFIT. Okay. The place that I work now does have a treatment center specifically for people who need 24-7 care with RFID. Um, but that is because it didn't exist in the in the field, or it's not common in the field. So having one such unit at least provides an opportunity for people with more severe forms of it to have a place where all the programming is designed for people with RFID. What you'll see in other treatment centers, even within the ones where I work, is that the treatment is individualized and there'll be some separate programming that can occur through the treatment day to make sure it's addressing the RFID components. So you want to make sure that the treatment is able to be individualized or that there's a special track of groups and treatment interventions for this diagnosis as compared to the other diagnoses that will be more common in the treatment center.

SPEAKER_00 57:21

So if somebody wants to learn more about treatment options, uh programs that are available that are specific to or understand RFID, where should they go?

SPEAKER_02 57:32

They can certainly look at the treatment center where I oversee it's the Emily program, and it's www.emily program.com. There'll be plenty of information on the website. Um there's also great information on the Alliance for Eating Disorders. Uh, they have a lot of the information on where to get help for specific disorders. There's also information available through the National Eating Disorder Association. Um, and if you check out their websites for either of those organizations, there'll be plenty of tips and opportunities for frequently asked questions for you to get information.

SPEAKER_00 58:10

It's good to have uh reliable sources that we can get our information from. And you are now one of them for us. So thank you. Also, recovery.com has lists of treatment centers and other treatment options across the globe. And if you put in eating disorders or RFID, you'll be able to look specifically for those. Thank you again. Thank you so much. And we will be back next week to continue this discussion, and we'll be focusing instead on another lesser known eating disorder called orthorexia.