Eating Behaviors 24 (2017) 49–53

Contents lists available at ScienceDirect

Eating Behaviors

Clinical presentation and outcome of avoidant/restrictive food intake

disorder in a Japanese sample
Yoshikatsu Nakai a,⁎, Kazuko Nin b, Shun'ichi Noma c, Seiji Hamagaki d, Ryuro Takagi d,
Satoshi Teramukai e, Stephen A. Wonderlich f
a
Kyoto Institute of Health Sciences, Kyoto, Japan
b
School of Health Sciences, Faculty of Medicine, Kyoto University, Kyoto, Japan
c
Department of Psychiatry, School of Medicine, Kyoto University, Kyoto, Japan
d
Takagi Psychiatric Clinic, Kyoto, Japan
e
Department of Biostatistics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
f
Department of Clinical Neuroscience, University of North Dakota, School of Medicine and Health Sciences, Fargo, ND, USA

a r t i c l e i n f o a b s t r a c t

Article history: We conducted a study of the clinical presentation and outcome in patients with avoidant/restrictive food intake
Received 25 July 2016 disorder (ARFID), aged 15–40 years, and compared this group to an anorexia nervosa (AN) group in a Japanese
Received in revised form 13 December 2016 sample. A retrospective chart review was completed on 245 patients with feeding and eating disorders (FEDs),
Accepted 19 December 2016
analyzing prevalence, clinical presentation, psychopathological properties, and outcomes. Using the DSM-5
Available online 21 December 2016
criteria, 27 (11.0%) out of the 245 patients with a FED met the criteria for ARFID at entry. All patients with
Keywords:
ARFID were women. In terms of eating disorder symptoms, all patients with ARFID had restrictive eating related
Clinical presentation to emotional problems and/or gastrointestinal symptoms. However, none of the ARFID patients reported food
Outcome avoidance related to sensory characteristics or functional dysphagia. Additionally, none of them exhibited
Avoidant/restrictive food intake disorder binge eating or purging behaviors, and none of them reported excessive exercise. The ARFID group had a signif-
Anorexia nervosa icantly shorter duration of illness, lower rates of admission history, and less severe psychopathology than the AN
group. The ARFID group reported significantly better outcome results than the AN group. These results suggest
that patients with ARFID in this study were clinically distinct from those with AN and somewhat different
from pediatric patients with ARFID in previous studies.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Avoidant/restrictive food intake disorder (ARFID) is a new diagnos-
tic category introduced in the section on feeding and eating disorders
in the fifth edition of the Diagnostic and Statistical Manual (DSM-5:
American Psychiatric Association, 2013). ARFID replaces the DSM-IV di-
agnosis of feeding disorders of infancy or early childhood (American
Psychiatric Association, 1994) to improve the clinical utility by adding
greater detail to the diagnostic criteria and widening the criteria to be
applicable across the lifespan (American Psychiatric Association, 2013).
Patients with ARFID may present with clinically significant avoidant/
restrictive eating, leading to weight loss or faltering growth, significant
nutritional deficiency, dependence on enteral feeding, or oral nutrition-
al supplements and/or a marked interference with psychosocial func-
tioning. These patients lack the preoccupation with body weight/
shape found in patients with anorexia nervosa (AN) and bulimia
⁎ Corresponding author at: Kyoto Institute of Health Sciences, Miyako Bldg 502,
Karasuma Oike Agaru Higashigawa, Nakagyo-ku, Kyoto 604-0845, Japan.
E-mail address: ynakai@helen.ocn.ne.jp (Y. Nakai).
nervosa (BN). The ARFID group also demonstrates behaviors and symp-
toms specific to this disorder, including food avoidance, selective eating,
functional dysphagia, appetite loss, and abdominal pain (American
Psychiatric Association, 2013; Norris, Spettigue, & Katzman, 2016).
The rates of ARFID have been reported to range from 5% to 22.5%
among pediatric eating disorder programs (Fisher et al., 2014; Forman
et al., 2014; Nicely, Lane-Loney, Masciulli, Hollenbeak, & Ornstein,
2014; Norris et al., 2014; Ornstein et al., 2013; Strandjord, Sieke,
Richmond, & Rome, 2015). Studies have consistently demonstrated
that compared to patients with AN or BN, ARFID patients are younger,
show a higher proportion of males, and are commonly diagnosed with
comorbid psychiatric and/or medical symptoms (Norris et al., 2016).
At present, the body of literature examining the rates of ARFID in
adult patients is extremely limited. One study reported that 4 out of
45 malnourished adult patients were categorized as having ARFID, but
there was no clinical presentation of these patients (Tanaka et al., 2015).
Very little has been published on the treatment and outcome of pa-
tients with ARFID (Norris et al., 2016). One previous study, a multi-cen-
ter analysis of outcomes in pediatric patients with a feeding and eating
disorder, reported that fewer ARFID patients attained weight recovery

http://dx.doi.org/10.1016/j.eatbeh.2016.12.004
1471-0153/© 2016 Elsevier Ltd. All rights reserved.
50 Y. Nakai et al. / Eating Behaviors 24 (2017) 49–53

than other groups of feeding and eating disorders (Forman et al., 2014).
Another published retrospective study in pediatric patients hospitalized
for nutritional deficiency revealed that ARFID patients relied more on
enteral nutrition and required longer hospitalizations than AN patients
(Strandjord et al., 2015). To the best of our knowledge, there is currently
no report on outcomes in adult patients with ARFID. Hence, we conduct-
ed a study of clinical presentation and outcomes of patients with ARFID,
aged 15–40 years, in a Japanese sample, and compared this group to a
group of patients with AN, as defined by the DSM-5 criteria.
2. Methods
2.1. Participants
A retrospective chart review was conducted on a cohort of patients
who sought treatment for an eating disorder at Kyoto University Hospi-
tal between 1990 and 1997. Patients were included if they met the
DSM-5 criteria for a feeding and eating disorder (n = 245). The study
population was predominantly female (n = 239). Patients were exclud-
ed if they did not meet the DSM-5 criteria for AN or ARFID. Using the
DSM-5 criteria, 1 male and 107 female patients met the criteria for
AN, and 27 female patients for ARFID. One male patient with AN was ex-
cluded, because menstrual pattern was necessary for assessing full re-
covery in patients of this study. Fifty-seven patients with AN and 18
patients with ARFID were teenagers, aged 15–19 years. All of the 134 fe-
male participants, aged 15–40 years, were of Japanese ethnicity. Ethical
approval for this study was obtained from the Ethics Committee of
Kyoto University Graduate School and Faculty of Medicine.
We administered the Eating Attitudes Test (EAT: Garner & Garfinkel,
1979) and the Eating Disorder Inventory (EDI: Garner, Olmstead, &
Polivy, 1983) to quantify eating disorder pathology and general psycho-
pathology during the first consultation. The EAT contains 40 items, in-
cluding items related to symptoms and behaviors common to patients
with eating disorders, and provides an index of the severity of the disor-
der. The EDI is a widely used multidimensional inventory, consisting of
64 items that make up 8 subscales, 3 of which measure eating disorder
pathology (drive for thinness, bulimia, body dissatisfaction), and 5 that
measure psychopathology commonly associated with, but not unique
to, eating disorders (ineffectiveness, perfectionism, interpersonal dis-
trust, interoceptive awareness, and maturity fears). The validity of Japa-
nese versions of these measures has been previously documented
(Nakai, Fukushima, Taniguchi, Nin, & Teramukai, 2013).
After 3 sessions of assessments and interventions designed to in-
crease motivation to undergo therapy, each patient began outpatient
treatment. The outpatient treatment program was a combination of in-
dividual psychotherapy (supportive psychotherapy) and somatic thera-
py (nutritional management), depending on the patients' needs. The
inpatient treatment program was a combination of individual psycho-
therapy (supportive psychotherapy) and somatic therapy (nutritional
management and enteral feeding), depending on the patients' needs.
The inpatient stay duration was b 3 months in all hospitalized patients,
as medical payments from insurance would be reduced in cases of inpa-
tient stays of N3 months. All treatment episodes were recorded. Follow-
up assessments during visit intervals covered eating behaviors, the
presence of fat phobia, and attitudes toward weight and shape.
2.3. Outcome study

2.2. Study variables at entry and during treatment After informed consent was obtained, eating disorder specialists
conducted an interview with participants and/or their parents by tele-
Patients were assessed by eating disorder specialists prior to treat- phone in 2001. Sixteen patients with AN at entry had died before fol-
ment at the first consultation, as previously documented (Nakai, Nin, low-up, but relevant information on their status at death could be
Noma, Teramukai, & Wonderlich, 2016). We collected various informa- obtained from their parents. Assessment of outcome was based on the
tion, including history of illness, factors related to the onset of the eating Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First,
disorder, eating behaviors, social functioning, familial relationships, the Spitzer, Gibbon, & Williams, 1995) and the Outcome Assessment Sched-
presence of fat phobia, attitudes toward weight and shape, the presence ule (OAS), developed by an outcome study group of eating disorders
of medical conditions and/or mental disorders, attitudes regarding supported by the Japanese Ministry of Health, Labour, and Welfare, as
treatment, and motivation to change, within the first 3 visits to the previously documented (Nakai et al., 2001; Nakai et al., 2014). This as-
units. Objective weight and height were measured during the first con- sessment takes the form of a guided interview, which is concerned
sultation and the current BMI was calculated. Premorbid and minimum with clinical features central to eating disorders. It evaluates the physi-
BMI in adulthood, age of onset, and duration of illness were assessed by cal state (BMI and menstrual pattern), eating behaviors (restrictive
self-reports. Age of onset was defined as the age at which a feeding and
eating disorder began.
DSM-5 feeding and eating disorder diagnoses were determined ret- Table 1
Comparison of clinical characteristics between the ARFID and AN groups at baseline.
rospectively by eating disorder specialists using various information re-
lated to the diagnostic criteria of feeding and eating disorders collected ARFID AN
from patients, family members, and other sources, and a checklist based n = 27 n = 107
Mean (SD) Mean (SD) p
on the DSM-5 diagnostic criteria, the Great Ormond Street criteria, and
related literature (Bryant-Waugh, 2013; Kurz, van Dyck, Dremmel, Age at entry (years) 19.0 (5.1) 20.1 (5.1) 0.307a
Duration of illness (months) 15.5 (10.0) 36.5 (43.7) b0.001a
Munsch, & Hilbert, 2016; Nicholls, Chater, & Lask, 2000; Sysko et al.,
BMI at entry (kg/m2) 14.2 (1.7) 14.6 (2.0) 0.347a
2015), as previously documented (Nakai et al., 2016). Differential diag- Premorbid BMI (kg/m2) 18.7 (1.7) 19.6 (1.8) 0.021a
nosis between ARFID and AN was made after consideration of the clin- Minimum BMI (kg/m2) 14.0 (1.8) 13.5 (1.8) 0.272a
ical symptoms, attitudes toward body weight and shape, and clinical
course over time, because some individuals with AN deny any fear of Number (%) Number (%) p
Restrictive eating 27 (100) 104 (97.2) 0.379b
fatness and do not recognize the medical seriousness of their low Binge eating 0 (0) 45 (42.1) b0.001b
weight at the first visit, and then later admit these symptoms Purging behaviors 0 (0) 40 (37.4) b0.001b
(American Psychiatric Association, 2013). There was no transition Enteral feeding 2 (7.4) 24 (22.4) 0.078b
from the ARFID group to the AN group during the course of treatment Overconcern on weight/shape 0 (0) 107 (100) b0.001b
Amenorrhea 27 (100) 92 (86.0) 0.039b
in this study. In addition, we investigated the contributing factors of
Excessive exercise 0 (0) 69 (64.5) b0.001b
poor nutritional intake, including emotional undereating, selective eat- Admission history 13 (48.1) 81 (75.7) 0.005b
ing since early childhood, fear for choking or vomiting, food allergies,
ARFID: Avoidant/restrictive food intake disorder, AN: anorexia nervosa, BMI: body mass
sensory issues, gastrointestinal symptoms, and other reasons index.
(Bryant-Waugh, Markham, Kreipe, & Walsh, 2010; Kurz et al., 2016; a
Two-sample t-tests.
Nicholls et al., 2000; Norris et al., 2014). b
Chi-square tests.
 Y. Nakai et al. / Eating Behaviors 24 (2017) 49–53 51

Table 2 sadness, worries, or bullying) and 19 (70.3%) reported gastrointestinal

Comparison of psychometric properties between the ARFID and AN groups at baseline. symptoms (e.g. abdominal pain, stomach bloating, or feeling full).
ARFID AN There was considerable overlap between these contributing factors.
n = 27 n = 107 p None of them reported food avoidance related to sensory characteristics
Drive for thinness 1.4 (1.6) 7.3 (5.9) b0.001a (e.g. extreme sensitivity to smell, taste, or texture) or functional dyspha-
Bulimia 0.4 (1.1) 5.6 (6.5) b0.001a gia (e.g. fear of choking or vomiting). A few patients with ARFID had en-
Body dissatisfaction 10.3 (3.1) 12.2 (4.7) 0.019a teral feeding. All the ARFID patients had amenorrhea. None of them
Ineffectiveness 5.4 (4.9) 10.5 (6.6) b0.001a
reported excessive exercise.
Perfectionism 3.6 (2.8) 5.3 (4.0) 0.021a
Interpersonal distrust 3.1 (3.1) 5.5 (3.7) 0.002a We compared clinical variables in the ARFID group to those in the
Interoceptive awareness 2.1 (3.3) 9.1 (7.8) b0.001a AN group (Table 1). There was no significant difference in the age at
Maturity fears 4.6 (2.6) 8.1 (4.3) b0.001a entry, BMI at entry, and minimum BMI between the 2 groups. However,
EAT 21.0 (8.1) 37.7 (17.4) b0.001a the ARFID group showed a significantly shorter duration of illness and
ARFID: Avoidant/restrictive food intake disorder. lower premorbid BMI than the AN group. The ARFID group showed sig-
AN: Anorexia nervosa. nificantly lower rates of admission history than the AN group.
EAT: Eating Attitudes Test.
a We compared the baseline psychopathological variables in the
Two-sample t-tests.
ARFID group to those in the AN group (Table 2). The ARFID group
showed significantly lower scores in all the subscales of the EDI and
eating, binge eating, and purging behaviors), psychological state (exces- EAT than the AN group.
sive concern over weight and shape), and psychosocial state (emancipa-
tion from nuclear family, personal contacts, and social adjustment) of 3.2. Outcome results
the previous 3 months. Scores range from 0 to 12, with higher scores in-
dicating better recovery. The validity of the OAS has been previously The mean duration of follow-up after entry was 85.2 months (SD =
documented (Nakai et al., 2001; Nakai et al., 2014). 21.1). There was no correlation between duration of follow-up and out-
Full recovery was defined as a BMI of N18.0 kg/m2, and no abnormal- come results (r = 0.007, p N 0.1). All patients were N 20 years old at fol-
ity of the menstrual pattern, eating behaviors and perception of body low-up. The mean age of AN patients and ARFID patients at follow-up
weight and shape, as assessed with the SCID-I and OAS, for at least 3 was 27.3 (SD = 5.6) and 25.7 (SD = 4.8) years old, respectively. Pa-
consecutive months. Active feeding and eating disorder diagnoses tients were categorized into 4 eating disorder status groups at follow-
were made based on DSM-5 criteria (American Psychiatric up (Table 3). The ARFID group showed significantly better outcome re-
Association, 2013), as previously described (Nakai et al., 2013; Nakai & sults than the AN group (p b 0.001). At follow-up, 14 (51.9%) out of 27
Nin, 2016; Nakai et al., 2016). Partial recovery was defined as a reduc- patients with ARFID and 38 (35.5%) of 107 patients with AN achieved
tion of symptoms to less than full criteria for at least 3 consecutive full recovery. Sixteen (15.0%) out of 107 patients in the AN group had
months. The validity of these procedures was previously documented died before follow up; however, no patients with ARFID died during
(Nakai et al., 2001; Nakai et al., 2014; Nakai et al., 2016). the course of the study.
We compared the scores of the variables on the OAS at follow-up be-
2.4. Statistical analyses tween the ARFID and AN groups. Sixteen deceased patients in the AN
group were not included in the comparative analysis (Table 4). There
All analyses were conducted using SPSS 13.0 software. Comparison was no significant group difference in the physical state scores (body
of clinical and psychopathological variables between the 2 groups mass index score and menstrual pattern). However, the ARFID group
(ARFID vs. AN) was carried out using two-sample t-tests or the Mann- showed significantly more improvement in terms of eating behaviors
Whitney's U test for continuous data (for normally or non-normally dis- (restrictive eating, binge eating, and purging behaviors), psychological
tributed data, respectively), and chi-square tests for categorical data. state (excessive concern over weight and shape), and psychosocial
Comparison of outcome variables between the 2 groups was carried state (emancipation from nuclear family, personal contacts, and social
out using the Mann-Whitney's U test. Spearman's correlations were adjustment) than the AN group.
used to evaluate the relationship among different variables.
4. Discussion
3. Results
Using a chart review, we studied the prevalence, clinical presenta-
3.1. Clinical and psychopathological variables at baseline tion, psychopathological properties, and outcomes of patients with
ARFID, aged 15–40 years. Our findings, although retrospectively
All the patients with ARFID were women. In terms of eating disorder assigned, reveal that 27 (11.0%) out of 245 patients with a feeding and
symptoms, all patients with ARFID had restrictive eating, but none of eating disorder meet the criteria for ARFID. Contrary to previous studies
them exhibited binge eating or purging behaviors (Table 1). In terms in pediatric patients (Norris et al., 2016), all patients with ARFID in the
of factors thought to be related to restrictive eating in the ARFID pa- current study were women. In terms of eating disorder symptoms, all
tients, 15 (55.6%) out of 27 patients reported emotional problems (e.g. patients with ARFID had restrictive eating, related to emotional

Table 3
Outcome category vs. diagnosis at entry.

Diagnosis at entry

ARFID AN
n = 27 n = 107

Outcome category Fully recovered n = 52 (38.8%) 14 (51.9%) 38 (35.5%)

Partially recovered n = 37 (27.6%) 10 (27.0%) 27 (25.2%)
Active eating disorder n = 29 (21.6%) 3 (11.1%) 26 (24.3%)
Deceased n = 16 (11.9%) 0 (0.0%) 16 (15.0%)

ARFID: Avoidant/restrictive food intake disorder.

AN: Anorexia nervosa.
52 Y. Nakai et al. / Eating Behaviors 24 (2017) 49–53

Table 4
Comparison of scores of the variables of Outcome Assessment Schedule at follow-up among the two groups.

ARFID AN
n = 27 n = 91
mean (SD) mean (SD) p

Physical state Body mass index score 7.1 (5.5) 8.7 (4.6) 0.181a
Menstrual pattern 8.9 (5.1) 8.1 (5.1) 0.489a
Eating behaviors Restrictive eating 11.3 (1.9) 9.0 (4.4) 0.012b
Binge eating 12.0 (0.0) 9.3 (4.6) 0.002b
Purging behaviors 12.0 (0.0) 9.6 (4.4) 0.004b
Psychological state Excessive concern over weight and shape 12.0 (0.0) 7.5 (4.9) b0.001b
Psychosocial state Emancipation from nuclear family 11.7 (1.1) 10.1 (3.6) 0.029b
Personal contacts 12.0 (0.0) 10.5 (3.4) 0.033b
Social adjustments 11.9 (0.8) 9.7 (3.9) 0.003b

ARFID: Avoidant/restrictive food intake disorder, AN: anorexia nervosa.

Scores range from 0 to 12, with high scores indicating better recovery, sixteen deceased patients in the AN group were not included in the comparative analyses.
a
Two-sample t-tests.
b
Mann-Whitney's U test.

problems and/or gastrointestinal symptoms. However, no ARFID pa-
tients in this study reported food avoidance related to sensory charac-
teristics or functional dysphagia. None of the individuals with ARFID
exhibited binge eating or purging behaviors. A few patients with
ARFID had enteral feeding. The ARFID group had a significantly shorter
duration of illness and lower rates of admission history than the AN
group. These results suggest that patients with ARFID in this study
were distinct in their clinical presentation from those with AN, and
somewhat different from pediatric patients with ARFID in previous
studies (Fisher et al., 2014; Forman et al., 2014; Nicely et al., 2014;
Norris et al., 2014; Ornstein et al., 2013; Strandjord et al., 2015).
We compared eating disorder pathology and psychopathology be-
tween the ARFID and AN groups using the EDI and EAT. The results of
the present study indicate that the ARFID group had significantly
lower scores in all of the psychopathological variables than the AN
group. These results suggest that ARFID patients had less psychopathol-
ogy than AN patients or that there may be a need to develop measures
that are better able to capture eating pathology and psychopathology
in ARFID patients.
Very little has been published on the treatment and outcome of pa-
tients with ARFID (Forman et al., 2014; Strandjord et al., 2015). In this
study, we conducted an outcome study in patients with ARFID and com-
pared this group to the AN group over a mean of 7.0 years. The ARFID
group showed significantly better outcome results than the AN group.
Although there was no significant difference in the physical state scores
between the ARFID and AN groups, the ARFID group showed significant-
ly more improvement in eating behaviors, psychological state, and psy-
chosocial state.
The reason why the ARFID group had significantly better outcome
results than the AN group in this study remains unclear. The AN group
in this study reported more binge eating/purging, higher eating disorder
psychopathology, a longer duration of illness, and higher rates of admis-
sion history, which are negative predictors of the outcome of AN (Keel &
Brown, 2010; Vall & Wade, 2015). Outcome of ARFID in previous studies
are inconsistent. One study in pediatric patients reported that AN pa-
tients had higher odds of weight recovery than ARFID patients 1 year
after presentation (Forman et al., 2014). Another study in pediatric pa-
tients reported that the percentage of patients achieving remission was
similar across both diagnoses, but that ARFID patients relied on more
enteral nutrition and required longer hospitalizations than AN patients
(Strandjord et al., 2015). The discrepancies among these previous stud-
ies and our present study are likely due to differences in the definitions
of recovery and differences in patient population.
Limitations of this study include its retrospective design and limited
sample size. The data came from treatment-seeking samples, performed
only at Kyoto University Hospital. Hence, care should be taken in gener-
alizing results from this sample. Despite these limitations, our findings
suggest that patients with ARFID, aged 15–40 years, in this study were
clinically distinct from those with AN, and somewhat different from pe-
diatric patients with ARFID in previous studies. Future studies involving
prospective data collection are necessary to further our understanding
and conceptualization of ARFID.
Funding
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or non-for-profit sectors.
Contributors
YN, KN and SN conceived the study design and methods. YN, SH and RT recruited par-
ticipants and collected the data. YN and ST conducted the statistical analysis. YN wrote the
first draft of the manuscript. SAW contributed to writing the manuscript. All authors con-
tributed to and have approved the final manuscript.
Conflict of interest
The authors declare that they do not have any conflict of interest.
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