Q&A: Avoidant/Restrictive Food Intake Disorder in Crohn’s Disease and Ulcerative Colitis

In inflammatory bowel disease, empiric or overall food avoidance increases the risk for food avoidance and avoidant/restrictive food intake disorder.

“Patients with IBD often develop some form of food avoidance/restriction behaviors,” Berkeley Limketkai, MD, PhD, AGAF, FACG, explains. “The underlying drivers relate to several factors: conditioned fear of certain food types that are associated with aggravation of gastrointestinal symptoms, intentional avoidance of certain foods to ‘treat’ inflammation, recommendations to pursue exclusion diets, decreased appetite mediated by inflammation, and the development of an unhealthy relationship with food that is often also due to misconceptions gleaned from the Internet.”

This behavior, depending on disease severity, can start with empiric or overall food avoidance during IBD flares to reduce the risk for symptoms. Some patients may also attempt to use diet as a form of nutritional therapy, Dr. Limketkai continues.

A paper published in Clinical Gastroenterology and Hepatology by Dr. Limketkai and colleagues examined the prevalence of avoidant/restrictive food intake disorder (ARFID) in patients with IBD, risk factors for the condition, and the association with risk for malnutrition. Physician’s Weekly (PW) spoke with Dr. Limketkai to learn more about ARFID, awareness of ARFID among IBD clinicians, and the unmet needs of patients with the condition.

PW: How does restrictive eating in patients with IBD lead to ARFID?

Dr. Limketkai: Patients with particularly severe and/or protracted disease activity who engage in empiric or overall food avoidance may eventually arrive at a narrow diet, hesitant to broaden it out of fear of experiencing a return of symptoms and/or disease activity. In one of our previous studies, we found that self-reported gluten sensitivity was associated with having had a flare in the previous 60 days.

In another study, food avoidance was common even among patients in clinical remission. While more common among those with active symptoms, food avoidance is still present among those in clinical remission, just at significantly lower rates. A positive ARFID screen was present in 17% of that population, which is consistent with the prevalence of ARFID estimated in studies for other gastrointestinal disorders (12% to 21%).

The most serious complication of ARFID is protein-calorie malnutrition, which, depending on severity, can lead to dysfunction in every organ in the body.

How much awareness of ARFID is there among IBD clinicians?

Recognition of malnutrition and screening for it is not the norm for IBD clinicians, primarily because they must address a myriad of issues with very limited time. It also has not been understood until very recently; the earliest studies of ARFID in IBD emerged in approximately 2021.

There has, nonetheless, been a progressively growing recognition of the importance of this in recent years, as evidenced by the amount of chatter on the topic at national conferences. Also, the scope of the clinical practice may impact recognition and awareness; for example, patients who are referred to GI dietitians will be screened for malnutrition as part of the standard nutrition assessment.

How common is ARFID, and how should clinicians address it?

Food avoidance and restriction can be as high as 93% among patients with IBD. Also, as I noted earlier, food avoidance occurs even when patients are in clinical remission.

Given this high prevalence and the potential complications of malnutrition, clinicians must screen for altered eating behaviors or, at the very least, risk for malnutrition. Fortunately, the malnutrition screening tool is very easy, with 2-3 questions. I screen virtually all my patients. It takes very little time, and patients do not hesitate to answer the questions.

Malnutrition can also be detected with a physical examination. If a risk of malnutrition is detected, I would refer patients to a GI dietitian, who can conduct a more extensive inquiry and provide recommendations for nutritional interventions.

What additional research is needed in this area?

Social determinants of health, particularly food insecurity, are understudied with these conditions. Having a healthy diet can be expensive. Lower-income patients are at higher risk for having significantly fewer options for food than middle- or high-income patients, especially when presented with foods that may aggravate symptoms.