Picky Eating Research Articles

Epidemiology of Avoidant/Restrictive Food Intake Disorder

Avoidant/restrictive food intake disorder (ARFID) is a relatively new category within DSM-5 feeding and eating disorders, which expands beyond developmentally normative picky eating. Given its recent introduction to the diagnostic nomenclature, research on the epidemiology of ARFID is in its infancy. Prevalence estimates for ARFID vary considerably by methodology, setting, and population, but growing evidence suggests that ARFID is just as common as other more well-known eating disorders, affecting approximately 0.3% to 15.5% of children and 0.3% to 4.1% of adults. Despite common misconceptions, ARFID impacts a wide range of individuals across ages and genders, and both medical and psychiatric comorbidities are common. Limited research has investigated prognosis, but existing longitudinal studies highlight the persistence of the disorder and the possibility of diagnostic crossover to other eating disorders. [ Psychiatr Ann . 2024;54(2):e42–e46.]

Differential Diagnosis Between Avoidant/Restrictive Food Intake Disorder and Anorexia Nervosa

Differential diagnosis between avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa may be challenging due to shared clinical features. Diagnostic criteria for ARFID prohibit disturbance of one's body shape/weight. In contrast to body image disturbance, body image dissatisfaction is normative and ubiquitous and may characterize those with ARFID. Distinguishing between body image disturbance and dissatisfaction is critical to derive accurate diagnoses. We compare these constructs, highlighting that body image dissatisfaction rises to the level of clinically significant body image disturbance when it results in: (1) behavioral symptoms, such as persistent behavior that interferes with weight gain; and/or (2) eating disorder cognitions, such as a distorted perception of one's shape/weight or overvaluation of shape/weight. We illustrate the application of this definition via a brief case example and conclude by providing recommendations to aid providers in differential diagnosis between ARFID and its most similar eating disorder, anorexia nervosa. [ Psychiatr Ann . 2024;54(2):e37–e41.]

Multidisciplinary Treatment of Avoidant/Restrictive Food Intake Disorder

Given that research into the treatment of avoidant/restrictive food intake disorder (ARFID) is in its early phases, there is a paucity of evidence-based guidelines directing best practices. However, there is still a need for clinicians to access summations of literature to guide clinical decision-making. Early data on the treatment of ARFID highlight the importance of a multidisciplinary team that can provide medical, pharmacologic, nutritional, and psychological care. While medical treatment is often informed by care guidelines for other eating disorders, pharmacological management often focuses on ARFID's psychiatric comorbidities. The psychological treatments with the strongest current evidence for ARFID include family-based therapy for young children, and cognitive-behavioral therapy for older children, adolescents, and adults. [ Psychiatr Ann. 2024;54(2):e51–e55.]

Exploring Family Care Journeys to Inform Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder and Somatic Symptom Disorders

Avoidant/restrictive food intake disorder (ARFID) and gastrointestinal (GI)-related somatic symptom and related disorders (SSRDs) commonly co-occur, and both are associated with confusion in the process of accessing treatment. Furthermore, health professionals report low confidence in providing care for these conditions. Using a life history methodology, we explored the journeys of children and their parents with the diagnosis and treatment of ARFID and/or SSRDs and examined themes in barriers and facilitators to care. Six families with children (4 boys and 2 girls; 8–14 years old) with a diagnosis of ARFID and/or GI-related SSRD were recruited from a pediatric tertiary-level hospital. Interviews were conducted with four parents alone, and two parent-child dyads. Participants provided rich histories of the child’s health journeys with variation in the development of ARFID and GI-related SSRDs and subsequent management. Diagnostic uncertainty, the emotional impact of this journey on families, and systemic barriers to accessing treatment were themes of the healthcare narratives. Validating the emotional impacts of the healthcare journey and building trust may be helpful to address the diagnostic uncertainty that families experience. Strategies to support adaptation of cognitive-behavioral approaches for with children with complex ARFID and/or SSRDs are discussed.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Avoidant/Restrictive Food Intake Disorder (ARFID)

CHILDHOOD PICKY EATING BEHAVIOUR AND ITS IMPACT ON THE GROWTH OF YOUNG CHILDREN: A SCOPING REVIEW

Background: Malnutrition occurs due to inadequate food intake and low daily energy intake, often associated with picky eating behaviour (PEB). Picky eaters have limited food choices and poor dietary diversity, leading to malnutrition. Therefore, this article aims to explore the impact of childhood eating behaviour on a young child's growth. Method: Articles were identified through six electronic search engines using 12 keywords. Articles were included if they met the following criteria: (1) sample of study involved young children (below six years old); (2) study outcome focusing on the impact of eating behaviour on the growth of the children (3) published in English. Studies were excluded if they were review articles, qualitative studies, and involved children with clinical health problems. Result: A total of 413 articles were screened, and 8 full-text articles were evaluated. The prevalence rates of selective eaters varied greatly from 25% in India to 77% in Iraq. The screening tools used for identifying PEB varied, with the Children’s Eating Behaviour Questionnaire (CEBQ) being the most commonly used tool. Short-term implications of PEB on children include the risk of poor diet intake and limited consumption of a variety of food groups, which can lead to adverse health outcomes. Meanwhile, long-term implications include the development of eating disorders in adulthood. Conclusion: Our findings reveal that PEB has had a significant impact on the growth of young children. Despite the increasing concern about the implications of PEB, there is a lack of sufficient research studies on the effects of this behaviour on the nutritional status of young children. Keywords: eating behaviour; picky eaters; nutritional status; growth; young children

Appetitive and psychological phenotypes of pediatric patients with obesity.

Obesity is a heterogeneous disease with variable treatment response. Identification of the unique constellation of contributors to obesity may allow for targeted interventions and improved outcomes. Identify empirically derived phenotypes of pediatric patients with obesity based on appetitive and psychological correlates of obesity. This cross-sectional study included patients aged 5-12 years who were treated in a weight management clinic and completed standard intake questionnaires including Child Eating Behavior Questionnaire (CEBQ), Vanderbilt ADHD Scale and Pediatric Symptom Checklist. Phenotypes were elicited using latent profile analysis of 12 indicators: eight CEBQ subscales, inattention, hyperactivity/impulsivity, internalizing and externalizing symptoms. Parents/guardians of 384 patients (mean age 9.8 years, mean BMI 30.3 kg/m2 ) completed the intake questionnaires. A 4-phenotype model best fits the data. Hedonic Impulsive phenotype (42.5%) exhibited high food enjoyment and hyperactivity/impulsivity. Inattentive Impulsive phenotype (27.4%) exhibited overall low food approach and high food avoid behaviours, and highest inattention. Hedonic Emotional phenotype (20.8%) scored the highest on food enjoyment, internalizing and externalizing symptoms. Picky Eating phenotype (9.3%) scored the lowest on food approach, inattention, hyperactivity/impulsivity, internalizing and externalizing symptoms. Appetitive traits and psychological symptoms appear to cluster in distinct patterns, giving rise to four unique phenotypic profiles, which, if replicated, may help inform the development of tailored treatment plans.

Therapeutic assessment as a brief and intensive intervention for avoidant restrictive food intake disorder, belching, and histrionic personality disorder: A case report

A 26-year-old female was hospitalized with complaints of repeated vomiting and weight loss (18 kg in 8 months); and incessant belching and nausea/regurgitation for 30 days subsequent to her COVID-19 treatment. After all the normal medical radiological reports, appropriate psychological and psychiatric evaluations were done. Incessant belching warranted a simple and flexible cognitive psychotherapy for histrionic personality with a therapeutic assessment technique. A total of 6 h of psychotherapy was delivered in three sessions. The belching and vomiting came down by 75% after the first extensive session, and almost 100% after the second session. However, mild belching reappeared, and after the termination-cum-booster session belching subsided till discharge and the first follow-up after 2 weeks.

Clinical characteristics, treatment course and outcome of adults treated for avoidant/restrictive food intake disorder (ARFID) at a tertiary care eating disorders program

BackgroundAvoidant/restrictive food intake disorder (ARFID) is now recognized as a feeding/eating disorder that affects individuals across the lifespan, but research on ARFID in general and particularly in adults remains limited. The purpose of this study was to describe the demographic and clinical characteristics of adults with ARFID seeking treatment at a tertiary care eating disorders program, and to describe the course and outcomes of treatment at three levels of care—inpatient, intensive outpatient, and outpatient individual therapy.MethodThis retrospective chart review study examined the charts of 42 patients who received treatment for ARFID between April 2020 and March 2023. Following diagnostic assessment, patients were referred to either inpatient treatment, intensive outpatient treatment, or outpatient individual therapy. All three levels of care involved individual cognitive behaviour therapy. Inpatients typically transitioned to one of the outpatient treatments as part of a continuous care plan. We examined demographic and clinical characteristics, treatment length and completion, and changes in key indicators during treatment.ResultsPatients were diverse with respect to demographics (e.g., 62% cisgender women; 21% cisgender men; 17% transgender, non-binary, or other gender) and comorbid concerns (e.g., 43% had neurodevelopmental disorders; > 50% had mood and anxiety disorders; 40% had posttraumatic stress disorder [PTSD]; 35% had medical conditions impacting eating/digestion). Most patients presented with more than one ARFID maintaining mechanism (i.e., lack of appetite/interest, sensory sensitivities, and/or fear of aversive consequences of eating). Treatment completion rates and outcomes were good. On average, patients showed significant improvement in impairment related to their eating disorder, and those who were underweight significantly improved on BMI and were not underweight at end of treatment.DiscussionThese findings add to the literature by indicating that ARFID patients are commonly male or have diverse gender identities, and have high rates of neurodevelopmental, mood, anxiety, and gastrointestinal disorders. We also found high rates of PTSD. The findings show promise for treatment outcomes across the continuum of care. Next steps in ARFID treatment and research include incorporating ARFID-specific assessments into routine care, and ongoing research investigating the efficacy and effectiveness of treatments such as CBT-AR.

Relationship of self-reported pica and avoidant restrictive food intake disorder symptomology with dimensions of impulsivity, perceived stress among Pakistani University students.

Pica and avoidant/restrictive food intake disorder are two of the three new eating and feeding disorders introduced in the DSM-5, this inclusion has drawn attention to the immediate need for research into their prevalence, diagnostic assessment, underlying risk factors and optimal treatment. There are very few studies available that explored the predictors or causes of these eating disorders specifically in Pakistani context. The objectives of the current study include (a) to estimate the presence of pica and avoidant/restrictive food intake disorder symptomology among young adults in Pakistan, (b) to examine the relationship between dimensions of impulsivity, stress and presence of pica and avoidant/restrictive food intake disorder, (c) to explore the mediation role of stress. The sample consisted of 660 young adults with age range 18-25years, recruited through convenient sampling. The respondents were provided with a questionnaire comprising of an informed consent, a demographic information sheet and self-report measures including PARDI-AR-Q to assess symptomology of pica and avoidant/restrictive food intake disorder, UPPS-P Impulsive Behaviour Scale to assess dimensions of impulsivity and Perceived Stress Scale to measure perceived stress. The findings show that 28 participants (4.2%) reported Pica symptomology, of which eleven participants indicated that they currently consume more than one non-food item. 19 respondents (2.8%) reported avoidant/restrictive food intake disorder symptomology. 13 respondents reported varying degrees of all three symptom clusters namely sensory based food avoidance, lack of interest in food, and fear of negative consequences of eating. Additionally, each of the dimensions of impulsivity was found to be positively correlated to the presence of pica and avoidant/restrictive food intake disorder. Perceived stress was identified as a mediating factor between each of the dimensions of impulsivity and presence of pica and avoidant/restrictive food intake disorder. Although current study focused on a particular age range, it has drawn attention to the necessity of screening and investigating other strata of Pakistani population for pica and avoidant/restrictive food intake disorder. The clinical utility of the present research resided in the identification of factors associated with pica and avoidant/restrictive food intake disorder, an information which can be used to tailor psychological interventions, modify existing ones, and inform the future research on evidence-based treatment.

The effect of providing Koya Nate on the appetite of stunting toddlers

The appetite experienced by toddlers is at risk of causing nutritional disorders, which can have a negative impact on health, such as stunting. Efforts are being made to overcome toddler appetite issues through innovation in the form of Koya Nate. This research examined the impact of Koya Nate, an innovative intervention, on the appetite of stunted toddlers in Surabaya. Using a quasi-experimental approach with a pre-post design, 16 toddlers aged 1-5 years participated, with 8 in the intervention group and 8 in the control group. The study found a significant influence on the appetite of toddlers in the intervention group after the intervention (Sig. 0.000), while there was no significant change in the control group without intervention (Sig. 0.157). A comparison between the two groups revealed a significant influence on appetite in the intervention group compared to the control group (Sig. 0.000). This suggests that Koya Nate has a positive impact on the appetite of stunted toddlers, addressing issues of picky eating. The study emphasizes the importance of innovative approaches in presenting food menus to toddlers facing appetite-related nutritional challenges. The findings highlight the potential of Koya Nate as an effective intervention for improving the appetite of stunted children, contributing to efforts to combat nutritional disorders and prevent negative health impacts such as stunting.

Comprehensive Assessment of Nutrition and Dietary Influences in Hypermobile Ehlers-Danlos Syndrome-A Cross-Sectional Study.

Disorders of gut-brain interaction (DGBI) are common in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorder (hEDS/HSD). Food is a known trigger for DGBI symptoms, which often leads to dietary alterations and, increasingly, nutrition support. We aimed to explore dietary behaviors and influencing factors in patients with hEDS/HSD. In a cross-sectional study, patients with hEDS/HSD were recruited from Ehlers-Danlos Support UK (nontertiary) and tertiary neurogastroenterology clinics to complete questionnaires characterizing the following: dietary behaviors, nutrition support, DGBI (Rome IV), gastrointestinal symptoms, anxiety, depression, avoidant restrictive food intake disorder (ARFID), mast cell activation syndrome, postural tachycardia syndrome (PoTS), and quality of life. We used stepwise logistic regression to ascertain which factors were associated with dietary behaviors and nutrition support. Of 680 participants (95% female, median age 39 years), 62.1% altered their diet in the last year and 62.3% regularly skipped meals. Altered diet was associated with the following: reflux symptoms ( P < 0.001), functional dyspepsia ( P = 0.008), reported mast cell activation syndrome ( P < 0.001), and a positive screen for ARFID, specifically fear of eating and low interest ( P < 0.001). Approximately 31.7% of those who altered their diet required nutrition support. The strongest predictor of requiring nutrition support was a positive screen for ARFID, specifically fear of eating (OR: 4.97, 95% CI: 2.09-11.8, P < 0.001). Altered diet is very common in the patients with hEDS/HSD we studied and influenced by functional dyspepsia, reflux symptoms, and ARFID. Those with ARFID have a 4-fold increased risk of requiring nutrition support, and therefore, it is paramount that psychological support is offered in parallel with dietary support in the management of DGBI in hEDS/HSD.

The mediating effect of dysmorphic concern in the association between avoidant restrictive food intake disorder and suicidal ideation in adults

BackgroundReflecting on the existing literature on suicidal ideation and Avoidant/Restrictive Food Intake Disorder (ARFID), this article investigates the complex relationship between them, hypothesizing about the possibility of dysmorphic concerns, being a mediator linking ARFID to suicidal ideation.MethodsUsing a snowball sampling approach, a survey was created on Google Forms and circulated across messaging applications and social media networks (WhatsApp, Instagram, Messenger). The sample involved 515 participants recruited between February and March 2023. The questionnaire included the following scales: Nine-items Avoidant/Restrictive Food Intake Disorder screen (NIAS), Dysmorphic Concern Questionnaire (DCQ), and Columbia-Suicide Severity Rating Scale (C-SSRS). When filling the questionnaire, respondents were warned that they can experience distress when answering certain questions and received information about mental health services. Five hundred fifteen adults participated in this study, with a mean age of 27.55 ± 10.92 years and 60.1% females.ResultsAfter adjusting over potential confounders (i.e., age, education, marital status, and household crowding index), analyses showed that dysmorphic concerns fully mediated the association between avoidant restrictive eating and suicidal ideation. Higher avoidant restrictive eating was significantly associated with more dysmorphic concerns, and higher dysmorphic concerns were significantly associated with the presence of suicidal ideation. Finally, avoidant restrictive eating was not significantly associated with suicidal ideation.ConclusionThis study highlights the potential indirect link between ARFID and suicidal ideation mediated by dysmorphic concerns. While no direct connection was observed between ARFID and suicidal ideation, the presence of dysmorphic concerns appeared to be a crucial factor in amplifying the risk of suicidal ideation in individuals with ARFID. This emphasizes the importance of addressing dysmorphic concerns alongside ARFID treatment to enhance mental health interventions and outcomes.

Effects of oral sarcopenia and malnutrition on the elderly

Abstract Old-aged adults often suffer from nutrient deficiency or appetite loss resulting from taste and smell degeneration, poor oral and dental functions, and chewing and swallowing difficulties in addition to having poor digestion and gastrointestinal tract absorption or delayed stomach emptying. Consequently, anorexia and less food consumption occur, not to mention the medication–food interaction that will aggravate insufficient nutrient intake. Moreover, aged people tend to isolate or suffer from depression, and insomnia, which can all weaken and empty their body and soul, leading to undernourishment. Older adults who are picky eaters are 2.5 times more prone to develop weakness in the future than average individuals, as well as a significant increase in disability risk by 40%. Anorexia nervosa, which refers to a decline in appetite or food intake, is common in this population because of the degradation of chewing and swallowing functions. In fact, those who are 65 years old and above have a 21.8% chance of choking on food at least thrice a week, for which 12.8% of them were diagnosed with dysphagia, statistically equivalent to 1 out of every 10 old-aged adults having a mild or more severe swallowing disorder.

Assessment of Picky Eating, Emotional Eating and Body Perception in Healthy Individuals

Assessment of Picky Eating, Emotional Eating and Body Perception in Healthy Individuals

Dietary Knowledge, Attitudes, and Behaviors Related to Obesity and Highly Underweight Among Urban Chinese High School Students: A Cross-Sectional Study.

This study aimed to identify dietary knowledge, attitudes, and behaviors related to obesity and highly underweight among urban Chinese high school students. Using the data of 403 high school students from a cross-sectional survey in 2022, multinomial logistic regression analysis was conducted with the body mass index as the objective variable (reference: normal weight), dietary knowledge, attitudes, and behaviors as the explanatory variables, adjusted for sex. Both obesity and highly underweight were most strongly related to incorrect dietary knowledge of desirable types of diets. Additionally, obesity was related to inappropriate dietary attitudes regarding the importance of diet, eating at irregular meal-times, and eating without chewing well, while highly underweight was related to picky eating and not having three meals per day, but not related to attitudes. The incorrect knowledge of desirable type of diet was related to both obesity and highly underweight, while other risk factors of knowledge, attitudes, and behaviors related to obesity or highly underweight differed respectively. These findings should be useful in examining effective nutrition education for urban Chinese high school students.

Maternal aggression and child temperament in families with ARFID children in Indonesia

Aggressive behavior in parenting is a crucial factor for the temperament of children. This study evaluated the relationship between the mother's aggressive behaviors and her children's temperament. The research design applied a cross-sectional survey by using multistage sampling. Two hundred forty-five participants joined this study by responding to a questionnaire. Good aggressive behaviors from caregivers to protect children against physical and psychological harm and danger were observed in mothers aged 26-35 (89.9%) and well-educated mothers (96.8%). The data showed that 4.54 (± 0.912) mothers protect their children from unhealthy foods. The temperament of children was not related to age (p-value = 0.372), mothers' educational background (p = 0.824), and mothers' job status (p = 0.705). Family income had no relation with the child's temperament (p-value = 0.253). There was no relationship between mothers' aggressive behaviors and the temperament of children in avoidant restrictive food intake disorder (ARFID) child cases. The number of children and the aggressive behavior from the mother affected the child's temperament. This study contributes insight into the interplay between a mother's aggressive behaviors and her children's temperament. Subsequent research could delve deeper into specific factors influencing children's temperament in the ARFID case.

A Study of Treatment Approaches for Children and Adolescents with Avoidant/Restrictive Food Intake Disorder

Eating disorders negatively affect people’s health. Common eating disorders including binge eating disorder, anorexia, and bulimia nervosa which are widely researched by researchers. New eating disorder, avoidant/restrictive food intake disorder (ARFID) introduced in DSM-5 which received less attention from researchers and the public. The research presented that children and adolescents are disproportionally affected by ARFID, but currently, there is a lack of understanding of ARFID and its treatments. This systemic review extracts relevant studies from three databases to identify available treatments of ARFID and assess the efficacy of each treatment. It aims to bring the public’s attention to ARFID, preventing delays in seeking healthcare services. Also, this review is designed to guide healthcare professionals for ARFID treatment selections as well as bringing suggestions for future research directions. Three databases (PubMed, Cochrane Library, Scopus) were searched from 2013–2023 for studies that relevant to treatments for children and adolescents with ARFID. 7 studies were included in this review. It reported that treatments for managing children and adolescents with ARFID in all 7 studies presented positive effects in the reduction of ARFID symptoms. The biggest limitation of the finding was the small sample size. The evidence showed that all different types of ARFID treatment had an improvement in ARFID symptoms. However, the definitive conclusion cannot be drawn before conducting research with an increased sample size. Children and adolescents’ motivation for changing eating behaviours and parent education can partially determine the efficacy of treatments.

Complementary Feeding Methods, Feeding Problems, Food Neophobia, and Picky Eating among Polish Children.

Proper nutrition during the first period of life is primarily related to meeting energy needs and providing essential nutrients that ensure the infant's normal physical and psychomotor development. Improper nutrition during this period, inadequate amounts of nutrients, inappropriate timing and manner of introduction of individual foods, can permanently alter metabolism and the course of physiological processes, increasing the risk of diseases such as obesity, allergic diseases, and cardiovascular diseases. This study aimed to verify how the method of complementary feeding influences the occurrence of food neophobia between 2 and 7 years of age, as well as to assess the different nutritional aspects resulting from the process of starting feeding other than breast milk and milk formula. In this study, 490 mothers and their children aged 2-7 years participated. The research tool was a questionnaire consisting of a child's dietary assessment and standardized questionnaires assessing food neophobia among children: Food Neophobia Scale for Children (FNSC) and the Montreal Children's Hospital-Pediatric Feeding (MCH-FS). In the study group of children, 238 (48.57%) had no Baby-Led Weaning Method (no BLW) method used during complementary feeding (CF), and 252 (51.42%) children used Baby-Led Weaning Method (BLW). According to the FNSC questionnaire, a high risk of food neophobia was found in 32.65% of the children studied and a medium risk in 39.80%. The medium risk of feeding problem occured in 11.63% of children, the high risk in 6.73% of children, and the highest risk in 6.94% (MCH-FS). No statistically significant differences were observed between the BLW and NoBLW groups. High risk of food neophobia occured in 1/3 of the children studied, but there was no relationship in the study group between the mode of CF (BLW/NoBLW) and the risk of food neophobia.

Clinical Characteristics of US Adolescents Hospitalized for Eating Disorders 2010-2022.

Eating disorders (EDs) affect a substantial number of American adolescents, with an increasing number seeking care for EDs during the coronavirus disease 2019 pandemic. We assessed the prevalence and clinical characteristics of adolescents hospitalized with EDs during 2010 to 2022. We used data from a national database of 12 children's hospitals (PEDSnet). Adolescents aged 12 to 21 years hospitalized for ED, disordered eating, binge ED, anorexia nervosa, bulimia nervosa, avoidant-restrictive food intake disorder (ARFID), or other EDs were included. Patients with complex or chronic illness or with EDs hospitalized for another reason were excluded. We analyzed demographic data, clinical characteristics, cardiac manifestations, coexistence of psychiatric conditions, and hospital stay characteristics. We included 13 403 hospitalizations by 8652 patients in this study. We found a gradual increase in hospitalizations for patients with EDs before the pandemic and a large increase during the pandemic. Mean age was 15.8 years with 85.9% described as female and 71.8% as white. Anorexia nervosa was the most common ED (57.5%), though hospitalization for patients with ARFID is increasing. Patients' median BMI percentage was 90.3%. Patients' malnutrition was classified as none (50.9%), mild (25.0%), moderate (18.6%), or severe (5.4%). Significant numbers of patients had a diagnosis of depression (58.5%) or anxiety (57.0%); 21.9% had suicidal thoughts. Nearly one-quarter (23.6%) required rehospitalization for ED treatment within 1 year. Hospitalizations for EDs among American adolescents are increasing, with a spike during the coronavirus disease 2019 pandemic. Significant numbers of patients hospitalized with EDs have suicidal thoughts. Trends in patients with ARFID require monitoring.