Compensatory Behaviors in Avoidant Restrictive Food Intake Disorder

ARFID is an eating disorder that is characterized by several factors such as: A clear lack of interest in eating or avoidance of food based on sensory characteristics (e.g. smell, taste, texture), fear of the aversive consequences of eating, such as persistent vomiting and thus, the body's energy and nutritional needs are not met. These factors must be related to one (or more) of the following criteria:

• Significant weight loss (or failure to achieve the expected weight gain or stunted growth in children)
• Significant nutritional deficiencies
• Addiction to oral dietary supplements or enteral nutrition
• Clear interference with psychosocial functioning
• In order for a disorder to qualify for ARFID, the following exclusions must be met
• Avoiding food may not be the result of a lack of access to food or be the result of religious or cultural orders (e.g. veganism)
• It does not occur exclusively in the course of anorexia nervosa or bulimia
• It cannot be attributed to a comorbid condition or is not explained by another mental disorder [1]
• When symptoms occur in the context of another condition or disorder, the severity of the eating disorder exceeds those routinely associated with the condition or disorder and necessarily requires additional clinical attention [2]
• In eating disorders, we often deal with compensatory behavior. The best known compensatory behavior is self-induced vomiting. Other examples of compensatory behavior in eating disorders include the abuse of laxatives, the abuse of diuretics (drugs to eliminate excess water), the abuse of enemas and compulsive exercise [3]
• As the name implies, compensatory behavior is usually an attempt to compensate for the number of calories or amount of food eaten, or to alleviate the negative emotions caused by eating. They are often driven by the fear of gaining weight for ARFID, a body image is not a reason for food avoidance, as is the case with other, more well-known, eating disorders. Therefore, compensatory behavior in patients with ARFID does not result from the desire to get rid of previously consumed foods that may contribute to weight gain

The very disorder that is ARFID can be considered as compensatory behavior, namely - avoidance and limitation. However, in the case of ARFID, the products that the patient is afraid of, refuses to touch and the consequences that may follow their consumption are avoided and limited [4]. A patient with ARFID consumes a very limited range of products that, in his opinion, are safe for him [2].

Compensatory avoidance behaviors result from a reluctance to touch, manipulate, smell or taste products, often because of their sensory properties. Avoidance of certain foods may also result from the fear of ailments that, in the patient's opinion, may appear after eating them [4].

Avoiding food intake is not always possible, therefore there are times when patients decide to try very small amounts of other products. Then, subsequent compensatory behaviors are observed, consisting in drinking very large amounts of water inadequate to the needs (even up to 1l) immediately after tasting even a minimal amount of food. The desire to get rid of the taste, smell and consumption of a given food is very high.

Typically, people with ARFID choose not to eat foods that they think are unsafe. However, it happens that they can manipulate such food products to a certain point, they willingly participate in the preparation of meals, but when it comes to the act of eating - they withdraw. This usually applies to adolescents and adults. Children with ARFID more firmly refuse to both manipulate and consume foods that they believe are not safe. Hence, in the case of ARFID in smaller children, diagnosis presents many problems, as ARFID may appear during the period of food neophobia, thus prolonging the time of diagnosis, which may, unfortunately, contribute to the formation of large nutritional deficiencies. In the case of young children, this is a critical period and any deficiency may cause irreversible health consequences [4,5].

Compensatory behaviors encountered in the daily practice of specialists dealing with eating disorders are usually related to the pursuit of a slim figure. In ARFID, the motivation for restrictive behavior is not distortion of the body image, but fear of the consequences of consumed products, fear of trying new products, sensory properties of products or a quick feeling of satiety. Hence, compensatory behaviors are related to the quick elimination of the fact of consuming a given food by consuming a large amount of water immediately after eating, washing hands quickly and thoroughly, or using only cutlery to manipulate food. In the case of ARFID, vomiting or the use of laxatives is not induced as compensatory behaviors. In the case of this disorder, it is precisely the avoidance of such unpleasant situations as e.g. vomiting, regurgitation, constipation, diarrhea that predisposes to avoiding or restricting food consumption.

1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association, Virginia, USA.
2. Bryant-Waugh R (2020) Overview of diagnosis and presentation. In: Bryant-Waugh R, Higgins C (eds.). Avoidant Restrictive Food Intake Disorder in Childhood and Adolescence: A Clinical Guide. Routledge, England, UK. Pg no: 272.
3. Colleen SSE, Labuschagne Z, Goldschmidt AB, Doyle AC, Grange DL (2012) The use of multiple methods of compensatory behaviors as an indicator of eating disorder severity in treatment-seeking youth. Int J Eat Disord 45: 704-710.
4. Dratwa AB, Szymanska D, Grajek M, Kotara KK, Szczepanska E, et al. (2022) ARFID-Strategies for dietary management in children. Nutrients 14: 1739.
5. Dratwa AB, Szczepanska E, Szymanska D, Grajek M, Kotara KK, et al. (2022) Neophobia-A natural developmental stage or feeding difficulties for children. Nutrients 14: 1521.