Session 1 - Be Body Positive

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/

Young People – Avoidant Restrictive Food Intake Disorder Introdution

Watch the video

Selective eating x ARFID

Neophobia

- Rejection of new, unfamiliar foods
- Usually presents in infancy - 18-24 months of age

Picky/fussy eating

- Mild feeding difficulty
- Some selectivity of foods and/or limited appetite

Feeding disorder

- Moderate to severe feeding difficulty
- Avoiding whole food groups
- Significant impact on physiological, behavioural & emotional

Selective eating x ARFID

Every child will have a phase where he will refuse new foods and will only eat preferred foods - this is expected and normal. As the child ages and becomes more familiar with specific foods, they will become less resistant to trying them (Dovey et al., 2008).

The severity of food neophobia is usually determined by the number of separate exposures it takes for the child to accept the food and at least try it. While most children will readily try a food after seven exposures, more severe presentations of food neophobia may require novel foods to be presented many more times before a child will accept it.

Some children will continue to have food difficulties – presenting as limited appetite or lack of interest in eating, sensitivity to texture/smell/taste/temperature/appearance of food, limited range of foods eaten and difficulties eating out. However, this will not lead to physical health consequences. Picky/fussy eating appears to be distinct from food neophobia but, like food neophobia, does not appear to merit clinical psychology attention (Kerzner et al., 2015).

Others will have severe food selectivity to the point of restricting a whole food group and this will have significant impact in their lives and their physical health

Dilemmas between Eating Difficulty and ARFID

it needs a multidisciplinary team to assess for ARFID. Diagnosis can be challenging given some complex presentation. There is a huge overlap with Autism. It is important to rule out any medical condition that might be impacting the eating like: Gastro symptoms – low interoception, low pain tolerance, sensory sensitivity, Autism, anxiety ; Medication that might affect taste ; Somatic symptoms. Also important to rule out any oral-motor difficulty that makes the child unable to eat/chew/swallow.

diagnosis

RED FLAGS and when to talk to the GP:

- Ongoing poor weight gain, weight loss
- Stunted height
- Ongoing choking, gagging, coughing during meals

- Ongoing problems with vomiting
- Vitamin and mineral deficiencies (are they eating foods from all food groups)
- Aversion/ avoidance of all foods in specific texture or food group

- Impact on psychosocial
functioning (i.e. difficulty with
eating out in restaurants / holidays
/ school / friends house)

Dilemmas

Strategies

Many different strategies can be used to treat both eating difficulties and ARFID. Not helpful to do when considering strategies:

Hiding foods they don’t like into foods they like

Letting them go hungry – they won’t eat anyway, even if hungry

Not giving their preferred food (especially if weight restoration isneeded). If weight is within normal ranges or overweight this can be discussed

Having the idea of “good” and “bad” food –food is food

Pressure to eat or finishing on time

To blame the parents – IT IS NOT PARENT’S FAULT!

Psychosocial aspect

Important aspects should be considered: eating out (at school, restaurants, holiday, other people house) can be a challenge, it needs further investigation about the severity of this (i.e. is able to eat at school when taking packed lunch or not even able to eat anything at all); Impact on family dynamic (i.e. constant stress and arguments, unable to eat at the table); Being able to engage socially when food is present (i.e. tolerating food during a sleep over). All these aspects need to be explored and understood better

What can we do to support the eating difficulties?

We know that routine works
well for most children

Think about offering 2/3 options
(maximum per day, so they also
engage on this)

Thinks about a visual timetable
and possibly a visual meal plan

Taking them to shopping and letting them
chosesome new foods

Reward system – can be helpful
with some children

To use hunger chart, to
help them track and
understand their hunger
signals

Having a separate cupboard can
be helpful sometimes

Distractions at meal times – can be helpful
in some cases, but ideally is a working in
progress to remove this so children can be
present whilst they are eating

What can we do to support
the eating difficulties?

Have your child be part of the meal where possible – helping to prepare, setting the table, or just bringing their own plate to the table.

Encourage them to serve others food, even
if they are not serving themselves

If possible, have a ‘learning plate’ in front of your child. They can serve a small amount of food on to this plate. There is no pressure for them to eat this food, but they can look/smell/touch/play with this food.

Have meals together as a family where possible, even if you are eating different things. This gives the child opportunities to be around different foods.

Have a familiar routine around mealtimes wash hands, set table, eat food etc.

When possible, ignore your child when he or she is doing things such as spitting, throwing or refusing food. Remember, you don’t want to encourage these behaviours by paying attention to them.

Make sure your child is sitting in a comfortable chair (feet on the floor)

Having a sensory box – example: fidget toys, stress balls (create together with the child)

It is important to offer foods your child already likes, as well as foods your child does not yet like. A good rule of thumb is to only offer three foods at a time. Include one to two foods your child already likes and one food your child does not yet like. If your child will not tolerate the new food on his or her plate, place the new food near him or her on a separate plate to help get your child used to the new food.

Present new foods in small bites and in fun or familiar ways to make it more likely that your child will eat it.

Parents working together (using same strategies) towards the same goal, so the child know what to expect

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 losing 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

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

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

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).