JAMDA xxx (2017) 1
JAMDA
journal homepage: www.jamda.com
Letter to the Editor
Anorexia of Aging and Avoidant/
Restrictive Food Intake Disorder
To the Editor:
Undernutrition affects approximately 5%-10% of community-
dwelling older adults, and is linked with an increased risk of
infection, functional decline, and early mortality.1,2 Age-related
undernutrition, manifesting as weight loss, is termed the
anorexia of aging, and has a multitude of causal factors including:
appetite loss, difficulty swallowing, frailty, depression, dementia,
and poverty.3 However, although many of the causes of undernu-
trition are well established in older adults, approximately 25% of
cases have no known cause.4
This begs the question: how many undernutrition cases with
no known cause can be attributed to avoidant or restrictive
eating by the older adult? A newly recognized condition
reflecting this disordered eating behavior in adults has been
added to the Diagnostic and Statistical Manual of Mental Disorders,
known as Avoidant/Restrictive Food Intake Disorder (ARFID).5
ARFID is characterized by selective (“picky”) eating wherein an
individual avoids or restricts certain foods.6,7 This avoidance is
sensorydavoiding particular foods because of taste, texture,
smell, or appearance6,8 [ie, avoiding the eating of lumpy foods
because of functional dysphagia (fear of swallowing)].8
ARFID presents clinically as undernutrition or failure to gain
weight because of a restriction in food intake, and can often result
in micronutrient deficiencies and a reliance on nutritional supple-
mentation or enteral feeding.6e8 Psychosocial impairment may also
be present, with an affected individual disengaging in social ac-
tivities that involve eating.6 ARFID is different from anorexia
nervosa and bulimia per se, in that individuals do not have a
disordered body image, or a wish to change their body shape or
weight.8 Affected individuals often eat a narrow range of foods6 and
are likely to have comorbid anxiety.6,8 This is not due to food un-
availability, coexisting medical/psychiatric problems, or an in-
dividual’s cultural traditions.5,7,8
Individuals of all ages can be diagnosed with ARFID.5,7 How-
ever, there is a distinct absence of research into ARFID in older
adults; its prevalence and impact on clinical outcomes is not
known. It is also unclear whether ARFID increases in prevalence
with age, or how to best manage the condition. In younger chil-
dren, behavioral therapies can be effective in managing ARFID,9
although it is not known if these therapies are effective in the
older adult.
http://dx.doi.org/10.1016/j.jamda.2017.01.020
1525-8610/Ó 2017 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Thus, given the lack of evidence-based research into ARFID in older
adults, an urgent call for research into ARFID, including its appropriate
management, is recommended. It is also advocated that clinicians be
aware of ARFID as a potential condition underpinning the anorexia of
aging, and the “geriatric giant” conditions of frailty and sarcopenia.
For example, several dysfunctional eating patterns in older adults,
such as eating a nonvaried diet10 may be attributed, at least in part, to
ARFID. Screening for both selective eating symptoms6 and appetite
loss11 may play an important role in the early identification of ARFID.
Acknowledgment
ED is funded by an Australian National Health and Medical
Research Council (NHMRC) Early Career Fellowship (Grant Number:
APP1112672).
References
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11. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: Simple
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Elsa Dent, PhD
Center for Research in Geriatric Medicine
School of Medicine
The University of Queensland
Brisbane, Australia