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Session 1

Avoidant Restrictive Food Intake Disorder

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Young people information

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WELCOME
TO MODULE 2

Welcome to Module 2! This module has been designed for parents and carers of young people with Avoidant/Restrictive Food Intake Disorder (ARFID), as well as professionals. You’ll learn how to offer support, and try some of the tools the NHS use with young people.

Information on Avoidant Restrictive Food Intake
Disorder (ARFID)

Support and in-depth information

Learn strategies

Download Sessions once complete

Brought to you by

East London
NHS Foundation
Trust

NELFT NHS Foundation Trust

- NELFT NHS Foundation Trust
https://www.nelft.nhs.uk/
- East London NHS Foundation Trust
https://www.elft.nhs.uk/
Avoidant Restrictive Food Intake Disorder Introdution

Watch the video

Welcome to Module 2 - Here we will learn more about Avoidant Restrictive Food Intake Disorder (ARFID)

We created this material to support you on understanding more about the eating difficulties that are present

We also give you some strategies to put into practice and improve your eating

We encourage you to use this with someone that can support you and maybe can explain the information in a different way
(it can be a parent, even a friend)

We understand that it might be overwhelming at first, so take your time to go through this

What is ARFID?

People with ARFID eat a very limited variety or amount of
food and it causes problems in their lives.

These problems may be health related, like loosing too
much weight, or not getting enough nutrients.

These problems may be social, like not being able to
eat meals with others.

Avoidant Restrictive Food Intake Disorder (ARFID) is different from other eating disorders, like anorexia nervosa, because people with ARFID do not worry much about how they look, or how much they weigh.

Instead, people with ARFID might have one, two, or all three of these Important concerns:

1

1. Some people with ARFID find that some foods have strange or strong tastes, textures or smells, and they feel safer eating foods that they know well.

2

2. Others have had scary experiences with food, like throwing up, choking or allergic reaction, so they may avoid the foods that made them sick, or stop eating altogether.

3

3. Others don’t feel hungry very often, think eating is a chore, or get full very quickly.

What is ARFID?

It's important to understand that someone with ARFID is not just being “picky” or “stubborn”

People with ARFID have underlying biological traits that initially made their eating habits a logical choice

Once established, a pattern of food avoidance can become longstanding and highly resistant to change

There are helpful steps you and your families can take that can interrupt these patterns of behaviour.

What is ARFID?

THINGS YOU MIGHT HAVE NOTICED….
  • Sensitive to smell, look, taste, texture or all together
  • Not feeling hungry, forgetting about eating, feeling full very quickly, not “liking” to eat, no interest in food or all together
  • Anxious temperament
  • Fear of eating because it might cause vomiting, choking, gaging or all together
NEGATIVE FEELINGS ABOUT FOOD
  • Fear of new foods and not wanting to try new foods
  • Smelling the food before trying
  • Thinking that it won’t taste good anyway so it might be better not trying
  • Thinking the food will make them sick/ vomit/ choke
  • Not wanting to eat a food once eaten because it caused some reaction in the past (allergy, vomit, choke)
HEALTH CONSEQUENCES
  • Weight loss
  • Reduced hunger
  • Vitamins and minerals deficiencies
  • Difficulty with gaining weight
  • Gut symptoms (i.e. upset stomach)
  • Feeling full quickly
  • Constipation
  • Not getting taller
ACTING DIFFERENTLY AROUND FOOD
  • Not eating at the dining table
  • Finding it difficult to eat at school
  • Not eating in front of other people
  • Not feeling hungry/not being able to say they are hungry
  • Feeling uncomfortably full
  • Sensitive to changes on how food looks
  • Noticing small changes in food and its packaging
  • Getting angry when they are forced to eat

Flavour preferences
are partly genetic.

There may be
evolutionary
advantages to
food preferences

You may be a “supertaster” - meaning you could have been born with a high concentration of taste buds on your tongue and dislike bitter foods, like vegetables

Foods like fruits, vegetables, and meats were those most likely to be poisonous when our ancestors were hunting and gathering.

Why do people have different preferences to food?

How does a limited diet keep ARFID going?

Eating the same foods all the time makes new foods taste even more different *Certain nutrition deficiencies can change the way food tastes, making new food even less appealing

Eating a very limited diet can also cause serious health problems. Eating preferred foods high in sugar and fat has been associated with diabetes and heart disease. Avoiding non-preferred foods, like fruits and vegetables, is associated with certain cancers

Eating a particular food over and over may also make you tired of that food and stop eating it, further limiting your diet

It may be hard to eat with others, causing you to miss out on opportunities to learn about new foods

What happens when you
become more careful about
your eating after a negative
experience with food?

Negative experiences with food such
as choking, vomiting, an allergic
reaction, or pain after eating can be
traumatic

These experiences might cause you
to limit your diet to prevent further
trauma

You might even avoid any
food that reminds you of
the traumatic experience
or stop eating
altogether

You may be using "safety behaviours" to try and prevent another traumatic experience from happening

-Taking very small bites
-Chewing for much longer than needed
-Only eating at familiar restaurants
-Not eating at all

Safety behaviours prevent you from testing negative predictions about eating *The more you avoid eating, the scarier it becomes!

What happens when you eat a limited
volume of food?

How hungry you feel and how much pleasure you get from eating is partly due to your genes.

Eating too little can promote excessive fullness when you do eat an adequate amount because your stomach capacity decreases with chronic food restriction.

Eating without a regular schedule of meals and snacks can impact your hunger, especially if you go long periods without eating.

Eating very little can cause you to feel full quickly, even though you are not getting enough nutrients.

How does eating very little keep ARFID going?

Even if you are born with a smaller appetite than others, eating very little may further reduce your appetite. This is particularly true if you also limit food variety

Eating a limited variety can decrease your ability to eat a sufficient volume of food because you get bored of eating the same things and then eat less of them

You may experience low mood, irritability, anxiety, apathy, difficulty concentrating, or social isolation

You may also experience medical problems such as; significant weight loss, problems with your bones, loss of muscle, decreased heart rate among others

Understanding Hunger

Over time eating too little confuses your hunger and fullness cues.

The best way to increase your awareness of hunger cues is to keep track of how hungry you feel before you eat and how full you feel afterwards.

To begin shifting your hunger cues, you will need to start eating at a 3 or 4 (neither hungry or full), rather than waiting for a 1 (extreme hunger). You will also need to keep eating until a 6 or 7 (extreme fullness) rather than stopping at 4 or 5 (neither hungry nor full).

Hunger Chart

  • 0
  • 2
  • 4
  • 6
  • 8
  • 9
  • 10
REALLY HUNGRY
REALLY FULL
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Early Snack
Breakfast
Mid morning
snack
Lunch
Pudding
Afternoon snack
Dinner
Pudding
Evening snack
Download this table

5 Step Model

Explore
Understand
Accept
Challenge
Change

Explore

What exactly are your child’s eating difficulties? Are there difficulties with the amount of food or the range of foods or both? Are these long standing difficulties or more recent? Is your child having any additional Supplements; if so how much, via what method and when is this given? Are the difficulties experienced across all environments; school, home, friends, relatives, restaurants?

Understand

What are the main drivers for avoidance and restrictive patterns of eating? Low interest in food? Sensory sensitivities? Concern about adverse consequences? Why might these be present; disrupted appetite; low desire to eat due to mood, stress, concentration, over arousal? Is restriction a side effect of medication? Are any concurrent illness or conditions affecting avoidance or restrictive eating such as oral-motor difficulties? Is your child a supertaster? Are their feelings of disgust or anxiety related to past negative experiences or worries picked up from others? Other difficulties such as ADHD, ASD, Intellectual Disabilities, family with restrictive eating difficulties?

Accept

Accepting this is how things are at present. Accepting it is okay to worry and it is likely your child’s eating is a result of normal fear related responses. Understanding and accepting why your child might be responding this way at present. Understanding that this does not have to be how things will be for ever but change can be a slow process.

Challenge

Identify what needs to change and whether there is real potential for change? What needs exploring first? How might this be achieved? What are the current consequences of eat difficulties and how might this affect what is changed first?

Change

To start making changes following this 5 step model sequence. Keep a record of changes, things that you try, what works and what doesn't. Appreciate the small changes and realistic about your expectations. Be as clear and consistent as you can minimising confrontation as much as possible.

Anxiety

We all feel anxious with various things, however, for some of us the anxiety is there all the time

This will impact your ability to communicate clearly, engage in activities, sleep and eat

When anxious, our appetite is reduced and therefore eating can be even more difficult

The anxiety also gives the feeling of “feeling sick” and for some of us, we will avoid eating due to the fear of being sick

However, the longer you stay without eating, the more “feeling sick” you will be, as there is no food in your body

TThat is why we want you to be able to understand how the anxiety impacts your body and think about strategies on how to better manage this

Anxiety exposure curve

The graph shows 3 lines:

Green - expected anxiety with new situations - anxiety starts lower, during the situation it goes higher and over time, it reduces as you know what to expect
Yellow - expected anxiety when you avoid situations - anxiety starts higher as you know you are avoiding a situation. Over time, the anxiety remains really high as there is no opportunity to exposure ourselves to new situations
Red - expected anxiety when you exposure yourselves to situations - anxiety starts lower, goes up when faced with a new situation, but then the more you exposure yourselves, the lower anxiety will be

How does Anxiety
feel in my body

Physical Sensations

Thoughts:

Behaviours:

What happens with your appetite when you are anxious?

How the physical sensation of anxiety affects your appetite/eating?

Try and think of some of these things and enter them in the boxes provided.

Overstimulation

If you are feeling too anxious/needing something to calm you down

  • Glitter jars
  • Stress balls
  • Fidget toys
  • Pop toys

Ways to Cope
with Anxiety

Do some deep breathing

Self-sooth with your senses - smell a rose/essential oil, watch something that you like contact with nature, listen to music

Relaxation techniques

Do the opposite of emotion I am feeling

Imagine myself doing the thing I am worried about and notice what happens with my body

Under stimulation

If you feel you need something to stimulate you

  • Massage cubes
  • Wobble cushions
  • Weight blanket (seek further advice for this)
  • Toys that vibrate

You can use self-sooth techniques before, during and after anxiety
provoking events. Below are some examples of how to use your senses to self-sooth.

Vision

Look at photos; zone out to a poster/picture; watch funny videos, read—a poem, book, song lyrics. Use sensory toys such as ooze tube or liquid motion hourglass

Smell

Listen to your favourite music and play it over and over again; pay attention to sounds in nature (birds, rain, thunder, traffic); listen mindfully to the sounds around you.

Movement

Rock yourself gently; stretch; go for a run; do yoga/ dance!

Hearing

Put on your favourite lotion; use a scented aftershave or body wash; put your favourite smell on a piece of fabric and smell it when you are anxious.

Taste

Pair new/fear foods with foods that you enjoy, have a favourite drink with your food.

Touch

Use sensory toys such as stress balls, squishies, your favourite fabric, pat your dog or cat; get a massage; brush your hair; hug or be hugged; put a cold cloth on your head; change into your most comfortable clothes

Download PDF

Food Traffic Light

This is a helpful tool to help you planning which foods are more willing to give it a go but also it helps you to see which foods you don’t feel prepared to have

Foods my parents/other people would like me to try…

Specific

What is your desired result? What exactly do you want to accomplish? Think about WHO, WHAT, WHERE, WHY WHEN.

Mesurable

How will you track your progress and outcome? Can you quantify or put numbers to your outcome?

Achievable

Is this goal realistic? Have you got the resources to achieve this goal? What factors may prevent you from achieving your goal?

Relevant

Why is this goal significant to you? What effect will achieving this goal have on your life and on others?

Timely

When will you achieve this goal? If your goal is large, try breaking it down into smaller goals with incremental deadlines.

SMART Goals

Goal:
Benefits of Achieving Goal?
How will you know where you are there?

SMART Goals

Food Chaining is a way of taking a food that you like and slowly adding subtle variations to this food until you can tolerate new ones.

This can be done in different ways and step by step.

It is important that you think about food that might be similar or get help if needed.

Some examples are in the next slide...

SMART Goals

Fries to Carrots

Learning to eat new colour

French fries

Sweet potato fries new colour

Butternut squash fries same shape & colour

Steamed carrots new texture

Roasted carrots same shape & colour

Roasted b.squash new shape

Food Chaining involves gradually and systematically diversifying the foods a person will eat.

For example:
You begin with a food that is currently accepted. You then consider what can be tolerated in relation to change i.e. colour, brand, texture, shape.You then identify a new food to try based on what can be tolerated. This new food is then introduced. This then restarts the process.

Potato chips to banana

Learning to enjoy fruit

Potato chips

Plantain chips

Banana chips

Banana

Frozen banana
slices

Freeze-dried
banana

BREAD TO PIZZA

Ways to support children in working towards goals they would like to achieve.

For example:
 If you have a child who would like to eat pizza but cannot tolerate this at the moment, food chaining can support breaking this down into manageable steps.

@Feedingpickyeaters

Chicken to fish

Learning to enjoy more protein

Fave nuggets

Fish nuggets

Fish sticks

Baked white fish

Fried white fish

Fish patty

6 Steps to Eating

1

Visual

What does it look like?

- What is the colour

- What size is it?

- What is the appearance?

2

Touch

What does it feel like?

- Is it wet or dry?

- Does it feel cold or hot?

- Does it feel bumpy or rough?

3

Smell

What does it smell like?

- Is it weak or strong smell?

- Is it a nice smell?

4

Taste

What does it taste like?

- Does it have a strong taste?

- Is it sweet or salty?

- Is it spicy?

5

Texture/Sound

What is the texture like?
What sound does it make
in your mouth?

- Does it feel loud when you chew it?

- Is it crunchy?

- Does it get soft quickly?
*Not expected to eat, it is ok to spit it out

6

Swallow

Any other sensation?

- Any other sensation?

* Small mouthful is ok and gradually increase quantity

Exposure isn’t expected to work straight away, it takes time and repeated experiences.
Start with the foods that cause less anxiety (so at the bottom of the hierarchy/ladder).
Remember, avoidance just causes more anxiety where as, exposure reduces anxiety over time.

Exposure Ladder

Food Exposure

Anxiety (100%)

%

%

%

%

%

%

%

Starting at the bottom of the ladder, identify the foods that cause the least amount of anxiety. As you move up the ladder the foods identified should gradually become more anxiety provoking.

Other Strategies

Remember change can take time! There is no right/wrong way OR specific steps to get 'there'. New foods should not be expected to be eaten straight away, sometimes it is just about exposure.

FADE IN

Start with high
proportion of preferred
food.

Gradually add in
novel food.

Gradually reduce the
amount of preferred
food and increase the novel.

Change it up

If you don't succeed at first, change it up! Try:

Raw
VS
Cooked
Salted
VS
Non-salted

X

spicee

Adding in preferred spices, sauces and condiments can be a great way for introducing novel foods. For example:

add
add

Interoceptive Exposure

Increased tolerance to full sensations can help you to eat enough.

Spinning on a chair
Gulping water

Progress Review

What has been going well?

What have been the challenges?

What has helped overcome these challenges?

What do you need continued support with?

Are you on target for your goals?

What are my next steps?

Well Done!

- Completed
You have

References or Creators Credit

My Notes

Supporting Videos

youtube ID KM4Xe6Dlp0Y

Looks aren't everything. Believe me, I'm a model.

youtube ID

Dove real beauty sketches. You're more beautiful than you think.

youtube ID f0tEcxLDDd4

If you could change one thing about your body, what would it be?

We hear you and see you!

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Barnardos
Mental Health Foundation
Thames Life
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Recently Added FAQ’s

The aim of this website is to support young people to identify and reflect on their eating behaviours and work toward a better relationship with food and their bodies through self-guided modules. Modules include exploring topics linked to food and eating behaviours and body image.
Eating behaviours can be described within a spectrum from optimal eating to eating disorders, with disordered eating sitting somewhere in the middle. Disordered eating can include normalised eating behaviours such as skipping meals, overeating, undereating, binge eating and extreme dieting. It can also include other behaviours associated such as obsessive or excessive exercise. Eating disorders, on the other hand, are diagnosable conditions characterised by persistent and extreme disturbances in eating behaviour. There are different types of eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, Avoidant Restrictive Food Intake Disorder (ARFID) and others. Eating disorders are accompanied by intense negative thoughts, feelings and behaviours towards food, weight and body image.  In summary, disordered eating is a more general term that encompasses a broad range of eating behaviours, while eating disorders refer to specific, diagnosed conditions with specific symptoms and criteria.
Disordered eating – a term used to describe eating difficulties that don’t require a clinical diagnosis – is becoming more common and can often be the first signs of someone developing an eating disorder. The NHS is treating record numbers of young people for eating disorders, so the need to intervene before diagnosis has become a matter of urgency. As ELFT clinician, Erica, says:  “A better eating disorders’ prognosis is linked to a shorter duration between onset of illness and start of treatment. Early intervention is therefore important to allow targeted support at a time when symptoms are more malleable and less entrenched, at times preventing the deterioration of the symptoms to developing into a full-blown eating disorder.”
There are many coping strategies for disordered eating, including:
  • Mindfulness and self-care practices, such as yoga, meditation, and exercise
  • Talking to a therapist or support group to process feelings and emotions
  • Practicing self-compassion and positive self-talk
  • Engaging in hobbies and activities that bring joy and fulfillment
  • Challenging negative thoughts and beliefs related to food and body image
  • Focusing on nourishing the body with balanced and satisfying meals
  • Reaching out to friends and loved ones for support
  • Following body positive accounts on social media, such as @bodiposipoet or @antidietriotclub
  • Seeking professional help, such as seeing a registered dietitian or seeking treatment for an eating disorder.
It's important to remember that everyone is different and what works for one person may not work for another. It's essential to find the coping strategies that work best for you and to seek help from a mental health professional if needed.

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